(as of 5/21/04) Name of Facility: Address of Facility: Number & Street Barangay & Municipality. Province/City Region. Name of Owner: Tel. No.

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1 Page 1 of 12 CHECKLIST FOR ACCREDITATION OF RESIDENTIAL DRUG ABUSE TREATMENT AND REHABILITATION CENTER (DATRC) (as of 5/21/04) Name of Facility: Address of Facility: Number & Street Barangay & Municipality Province/City Region Telephone Number: Name of Owner: Tel. No.: Address: Type of Accreditation applied for: Initial Renewal Date opened: Days/Hours of Operations: Classification according to: Ownership: Government Private Institutional Character: Institution-Based Freestanding Instructions: (1) Encircle (+) if item indicated is present and (-) if item indicated is absent. (2) All items with (*) should be posted in a conspicuously designated area. (3) This tool will be used by Regulatory Officer (R.O.) during inspection/monitoring prior to issuance of accreditation (initial/renewal). (4) This tool may also serve as a guide for self-assessment of the facility in preparation for inspection/monitoring visits.

2 Page 2 of 12 STANDARD(S) 1. MANAGEMENT STANDARDS 1.1 APPLICATION DOCUMENTS All application documents must be valid and properly filled up. FINDINGS INSPECTION/SURVEY MONITORING REMARK(S) Documentary Requirements: List of Personnel Name Position PRC license number and validity (if applicable) Status: P-Permanent/T-Temporary Educational Attainment Training Signature List of Equipments/Instruments Name of Equipment Date acquired with proof of purchase Quantity Functional status Floor Plan Properly labeled areas with adequate scaling Valid signature and seal of architect or engineer Certificates and Permits: (Based on DDB Board Regulation No. 5s 1991) The DATRC must comply with the following certificates and permits, which should be valid and current. They should be filled up and posted conspicuously at the reception area. Sanitary permit * Fire Safety Inspection Certificate* DTI/SEC registration* Enabling Act (for National DATRC) Board Resolution (for Local DATRC) Mayor s Permit* PRC Board Certificate/Training Certificates for the following*: DOH accredited Physician

3 Page 3 of 12 STANDARD (S) FINDINGS INSPECTION/SURVEY MONITORING REMARK (S) 1.2 MANAGEMENT RESPONSIBILITY The Center shall be managed effectively, efficiently and in accordance with its mission, vision and objectives Mission, Vision and Objectives * Mission, vision and objectives should be in accordance with the RA 9165 Comprehensive Dangerous Drugs Act of Known and understood by all personnel Management/Staff Meetings Management/Staff meeting should be held at least 2x a year or as needed with proof of attendance Documented minutes (reflecting the date, time, attendance, agenda and action taken of meeting) should be present and properly filed within the Center Continuing Program for Staff Development and Training There should be a policy/program for continuing program on staff development and training Proof of training through certificates memos, written reports, budgetary allocations, etc Procedures for handling complaints Protocol for handling complaints Record book

4 STANDARD (S) Department of Health INSPECTION/SURVEY FINDINGS MONITORING Page 4 of 12 REMARK (S) 1.3 MANPOWER Personnel and practices shall be in place to ensure the achievement of the mission of the rehabilitation center Staffing Pattern Organizational Chart * Organizational chart should be clearly structured indicating the names with pictures and designation Center Program Director/Administrator (Based on DDB Board Regulation No. 5s 1991) Name: Address: Tel. No.: Proof of qualifications/training like: PRC ID (valid)- if applicable PRC Board Certificate*- if applicable DOH Certificate of Drug Rehab Training conducted by Certificate No. List of trainings relative to management and rehabilitation of drug dependents Employment contract Written and notarized employment contract/appointment of the Director/Administrator.

5 Page 5 of 12 STANDARD (S) FINDINGS INSPECTION/SURVEY MONITORING REMARK (S) DOH accredited Physician (on call) (Based on DDB Board Regulation No. 5s 1991) Name: Address: Tel. No.: Psychiatrist (certified by Philippine Psychiatric Association) General practitioner List of trainings relative to management and rehabilitation of drug dependents Proof of qualifications/trainings like: PRC ID (valid) PRC Board certificate* Certificate of drug Rehab Training conducted by Certificate No Written and notarized employment contract of the Physician Other Professional Staff (Based on DDB Board Regulation No. 5s 1991) Position/Designation NAME PRC # Training relative to management and rehabilitation of drug dependents Remarks LICENSED DENTIST* LICENSED NURSE/MIDWIFE* LICENSED SOCIAL WORKER* PSYCHOLOGIST* *REQUIRED

6 Non-professional Department of Health Page 6 of 12 Position/Designation NAME Training relative to management and rehabilitation of drug dependents Remarks CLERK* OTHERS (houseparent, security guards, etc.,) *REQUIRED STANDARD (S) FINDINGS INSPECTION/SURVEY MONITORING REMARK (S) Personnel Records (Based on DDB Board Regulation No. 5s 1991) All records for each personnel should be within the rehab premises Curriculum vitae containing: Personal background Education Training & experience Job Description Detailed description of tasks, responsibilities and accountabilities Health Status Medical /health certificate Annual drug test report conducted by an accredited DTL foreigner (non-filipino) Personnel, (if applicable) Working permit issued by the Bureau of Immigration and Deportation is required Work Schedule Monthly schedule of duties and assignment posted within the rehab center Written and notarized employment contract for each personnel.

7 1.3.7 Procedure Manual: Administrative Policies (Based on DDB Board Regulation No. 5s 1991) Background of the center Department of Health Page 7 of Organizational chart Duties and responsibilities of personnel Documented duties and responsibilities of all personnel reflecting lines of authority, accountability, communication, and inter relationship Work schedule Personnel Management There should be a written policy for hiring, orientation and promotion for all levels of personnel Written policies for violations/suspensions/ terminations for all levels of personnel. Records of memos sent, if applicable Records Management The Center must have records management protocols to ensure systematic management of patient case files and administrative files Maintenance program The Center must have a preventive maintenance plan for the upkeep and maintenance of facility and equipment Fiscal Management The Center must have a sound plan of financing which gives assurance of sufficient funds to enable it to carry out its defined purpose and provide appropriate services for drug dependents Admission Protocols Inclusion\Exclusion criteria NO admission of patients with psychosis Dietary Management The Center shall have a sound plan of management, which ensures the provision of a well balanced diet meeting the dietary needs of the residents.

8 Page 8 of PHYSICAL FACILITY (Based on DDB Board Regulation No. 5s 1991) Adequate facility shall be in place for the safe and efficient operation of the Center General Floor Area Minimum of 400 sq. m. for every 30 patients Specific Areas Registration/reception/waiting area Living quarters Rooms for male patients beds three feet apart double decked bed one meter space from ceiling and upper and lower bed Rooms for female patients beds three feet apart double decked bed one meter space from ceiling and upper and lower bed Toilet /bath/lavatory (one for every 10 patients) Multipurpose/recreational area Dining area Kitchen sharps secured/locked

9 Page 9 of 12 STANDARD (S) FINDINGS INSPECTION/SURVEY MONITORING REMARK (S) Counseling/testing/examination room Administrator s/director s office storage of files secured Area for outdoor activity Emergency clinic provision for personal hygiene and excretory functions DATRC Utilities (Based on DDB Board Regulation No. 5s 1991) Proper ventilation like: Electric fan/air conditioner unit may be used for improved ventilation Adequate Lighting Adequate Water Supply Solid Waste Facility Practice of waste segregation Housekeeping There should be a written protocol for housekeeping Facility is kept clean, safe and odor-free There should be a program for pest and vermin control.

10 Page 10 of EQUIPMENT (S) and SUPPLIES Adequate equipment and supplies shall be in good working order. Cabinet and locker Dining table Electric fan Emergency medical cabinet/first aid kit Examining light Fire extinguishers Recreational equipment Refrigerator Sofa set Sphygmomanometer Stethoscope Stove Table and chair Telephone Thermometer TV and/or karaoke Typewriter/computer Weighing scale

11 Page 11 of TECHNICAL STANDARDS (Based on DDB Board Regulation No. 5s 1991) 2.1 CASE FILES There shall be an adequate system for management of case files of residents. Each case file should include: Intake Interview Physical Examination (done by Physician) Laboratory Urinalysis Stool exam Chest X-ray 12 L ECG ( 45 y/o and above) Psychological Testing Social Case Report Diagnosis (Clinical Impression): Treatment Plan (Treatment Modality Used): Progress Reports (Quarterly) Incident Reports Accidents Escapes Injury Critical Incidents/Crisis 2.2 Procedure Manual: TECHNICAL PROCEDURES (Based on DDB Board Regulation No. 5s 1991) Protocols for assessment Medical Service Psychiatric service Psychological service Social service Follow-up and after care Protocols for treatment and management (Treatment Modality Used) Protocols for Patient s Rights Patient rights during treatment and rehabilitation Physical privacy/confidentiality Informed choice and informed consent Disciplinary action/ measures

12 2.2.4.Protocols for other prescribed services Protocols for referral (including drug testing, emergency assistance, etc.) Residential/house care service Spiritual and religious services Sports and recreation services Structured program of activities Department of Health Page 12 of Protocols for rehabilitation Counseling program Work and vocational skill program Family program Protocols for support services Volunteer services Job placement referral (optional) In-house educational opportunities (optional) Inspected by: Date: Concurred by: Date: