आरोग्य एक ...

महाराष्ट्र शासन सार्वजननक आरोग्य नर्भाग

शासन क क्रमाांकः क - 2016 /प्र.क्र.251/आरोग्य-3 10 र्ा मजला, सांकुल इमारत,

गो.ते.रुग्णालय, मुांबई-400 001. तारीख: 22 ,2017.

:-

क क आरोग्य क क आरोग्य . एक आरोग्य

एक .

क आरोग्य क आरोग्य

क - क आरोग्य

- , , , इ. क . आरोग्य क , क आरोग्य क क , क आरोग्य - क ऊ आरोग्य , क

क क- (CSR) आरोग्य क

क क क क , आरोग्य क - - क , आरोग्य क - क , क ऊ . शासन क-

क आरोग्य क आरोग्य एक . .

शासन ननणवय क्रमाांकः क 2016/प्र.क्र.251/आरोग्य-3,

पषृ्ठ 5 पैकी 2

1. क क आरोग्य क - क क .

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5. क - क आरोग्य क .

6. आरोग्य - क - क

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शासन ननणवय क्रमाांकः क 2016/प्र.क्र.251/आरोग्य-3,

पषृ्ठ 5 पैकी 3

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8. एक आरोग्य क क क क क क क क क

- क क ऊ क

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9. एक . .क / /

/ क (Inspection

Format)

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10. क आरोग्य क क -

क आरोग्य क क क क , क आरोग्य

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11. आरोग्य क क क क एक क क एक क, क . क आरोग्य आरोग्य क

क क , आरोग्य क क .

शासन ननणवय क्रमाांकः क 2016/प्र.क्र.251/आरोग्य-3,

पषृ्ठ 5 पैकी 4

12. क - क क क आरोग्य क क क आरोग्य क क क . क - - आरोग्य क . आरोग्य क क क , क क क क . क क आरोग्य

क, आरोग्य , आरोग्य क क .

13. /

क क क . क क

क क क क क क .

14. क आरोग्य क क क क - 2

3 क, , क

क ( ).

15. आरोग्य क 108, 102, 104 . क क .

16. क आरोग्य क - क - क क आरोग्य क . क , एए ए /ए ए ,

आरोग्य क इ. / ऊ आरोग्य क .

शासन ननणवय क्रमाांकः क 2016/प्र.क्र.251/आरोग्य-3,

पषृ्ठ 5 पैकी 5

17. आरोग्य (Inspection

Format) आरोग्य क

.

सदर शासन ननणवय महाराष्ट्र शासनाच्या www.maharashtra.gov.in या सांकेतस्थळार्र उपलब्ध करण्यात आला असून त्याचा सांकेताक 201703221039398517 असा आहे. हा आदेश निजीटल स्र्ाक्षरीने साक्षाांनकत करुन काढण्यात येत आहे.

महाराष्ट्राचे राज्यपाल याांच्या आदेशानुसार र् नार्ाने.

( . .क ) सनचर्, महाराष्ट्र शासन प्रत,

1. महालेखापाल, महाराष्ट्र-1/2 (लेखा पनरक्षा) ( लेखा र् अनुज्ञयेता), मुांबई/ नागपूर 2. , क, , . 3. सांचालक, आरोग्य सेर्ा, मुांबई. 4. सहसांचालक,आरोग्य सेर्ा ( ) 5. उपसांचालक, आरोग्य सेर्ा, ( ). 6. नजल्हा शल्य नचनकत्सक, सामान्य रुग्णालय, ( ).

6. आरोग्य क ( ) 7. क आरोग्य क ( ) क ( ) 8. /कायासन अनधकारी, आरोग्य-3/ आरोग्य-3 / आरोग्य-4/सेर्ा-2/

सेर्ा-3/ सेर्ा-5/अथवसांकल्प, सा.आ.नर्. मांत्रालय,मुांबई. 9. ननर्िनस्ती (आरोग्य-3)

Roshani Dinesh Kadam Patil

Digitally signed by Roshani Dinesh Kadam PatilDN: CN = Roshani Dinesh Kadam Patil, C = IN, S = Maharashtra, O = Government Of Maharashtra, OU = Public Health DepartmentDate: 2017.03.22 16:19:28 +05'30'

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7

Hospital lnspection

Form

II'q

ll o$n il!!I, I nsneltio n Fo r E!

Name of Block:Name of District:

Catchment Population:

Sanctioned Beds -

Date of last supervisory visit:

Date of visit:

Name of'Hospital

Total Villages: Category ofHospital

Beds available by Additional specialty unirs -- Total Beds

Total beds occupied on date olvisit

Name& designation of monitor:

Write which is applicable withbudget fbr current financial ;-ear.

-]-___l

sent/Estimale awaitedLand

acquisition in progress.

Electricit-,- with power back up

in the fbrm olCenerator

Solar power packs

Rr*'*-s 24.i *at* srppl."

N*rt"rr.rt t.trph*"

C--leanliness inside

Cleanliness outside Hospital

Cleaning timetable displayed

and record ot'daily and weekly

cleaning time table available.

Boards ol hospital Fees, Board

of availability of free medicines,

services available displayed Y /N

Availability of complaint

register rvith register of action

taken on regarding complaints.

Citizen's Charter displayed -Whether board of RKS

Sepi.rrate fv{ale and Female

wards (at least by- partitions)

Avai lability of Nutritional

Rehabilitation Centre

I ;"ia.rrl Bl...l br"k

Date o[registration by FDA

Number of Blood collection

\\

Functional blood bag

refrigerators with chart tbr tenrp.

recording

Suft'icient no. of blood bags

available

Check register for number ofblood bags issued for BT in lastquarter

l. t4 Blood storage center operational

or not

Number of emergency bloodtransfusions since Apr l4

Number of planhed -blood

transfusions since Apr l4

l.l5 Blood component center

Date of registration by FDA

Date of Expiry

Number of Blood componentstransfused from Apr 14

PCV

Plateles

Fresh Frozen Plasma

Cryoprecipitate

r. l6 Separate room for ARSH clinicBMW

l.t7 Date of initial registration withMPCB

L18 Date of expiry

l. l9 Number of infection controlcommittee meetings this year

Number of accident reporting's

t.20 Color coded bags available

t.2l Needle burner

1.22 Puncture proof containers

1.23 Balance Stock of hypochloritesolution

Fire Safety protocols

t.24 Whether hospital registeredunder Maharashtra FirePrevention and Life SafetyMeasures Act. 2006

1.25 Whether fire safety audit carriedby District Fire Officer orLicensing agency

tI

2.8

2.9

2t0

3.7

-l.li

t9II

A

F--unctional of Lights, ceiling

Frnitioial o- lights. mobile

( ell counter 4 Parts

-ts

and resting Kits

I maging equiPment's

Functional C.T Scanner

f r-ct'ronal X-raY units

Mortuary cabinei

Bun with drill 2 sets

Eft--op.ratinginstruments2

--E\5

MeAical stori and F,Ss*irtiutibruss and lies:,'

EDL avai lable-nd dGplayed

Computerized inventoif management

IFA tablets

IFA tablets (blue)

l[iA syrup rvith dispenser.

Vit A sy'up

Ini Magnesium Sul

Availability of antibiotics

Labelled emergency tray at each workstationDrugs fbr hypertension, Diailments e.g PCM, metronidazole, anti-allergic

Adequate Vaccine Stock available

Pregnancy testing kits

Urine albumin and sugar testing kit

Gloves.Mckintosh@

Whether entries in softryare made on same daExpirydateregffiwhether any expiry dated medicines remainingin medical store.

Stock book updated and

Availability of function'at help dest<

wtrettre@Stethoscope, Hammer, Bp App, Auroscope,Tuning fork, torch, weighing machine

"t

Drugs - . .r -:'Yes:. No Remarks

5.1

5.2

5.3

5.4

5.5

5.6

5.7 ORS packets

5.8 Zinc tablets

5.9

5. t0 Ini Oxytocin5.1 I Misoprostol tablets5.12

5.r3

5. l4

5.15

S.No Supplies Yes No Remarks5.17

5.l8

5. l9 OCPs

5.20 EC pills

MMA kits5.21 IUCDs

5.22 Sanitary napkins

S.No Essential Consumables Yes No Remarks5.23

Medical store5.24 lMhether approved bv FDA5.2s

5.26

5.27

. . .;-,; :-;. :., ;...,1 .

:' arks,. , ,

6.1

6.2

6.3 whethert"tosiffi

Wh.tL* OPD p"pers has complaints, diagnosis

and treatment written

---If

r7

No. of sick children ret'erred

No. of Tubectomy

No. of Minilap

No. of children t'ully imnrunized

No. olchildren given ORS + Zini

No. olchildren given Vitamin A

No. of MTPs conducted in first trimester

No. of MTPs conducted in second trinrester

Number of Adolescents arrending ARSH clinic

Maternal deaths, if any

I births, if

Neonatal deaths, ifany

Infant deaths, ifany

according to GOI norms

Whether Z trays tipt as per guiEEiiiE

Whether partograph kept or not

Handwashing protocols displayeO anO

tbllowed

Whether stat}'nurses as per norms andtrained in SBA

Whether equiprne.,tras per norms.

Diet being provided free of charge

el t mottrers in-tiatea breast feeaingwithin one hour of normal deliZero dose BCG, Hepatitis B and OpV

Counseling on IYCF done

Coffil'rng o" FamilY Planning done

Mothers asked to stay for 72 hours

"t.Sqayrrrcnt bcing gircn bclirrc

lvlodc ot'JSY paynlcnt (Cashi bearer

checluclAccttunt Pu)"ce

Account Transl'er)

A"y .-f.ditrre incurred bY Mothers

on travel, drugs or diagnostics(P/ease

sive details)

tih orobins auestions and demotqllglilrL".

l.l Yci:: ,ii

Manage high risk Pregnancy

Frou iO" ess.ntial nervborn

care(thernttlrcgu lation. breastt'cedin g

ttaan'ae sick neonates and infants

Correctly uses Partograph

Correctly insert tUCD

?lroclroc t l,u ad m i n i s tcr v acc i nes

G*g^t'on orW*te in colour coded

Mhc'r.nce to IMEP (lnfection

Management and Environment

Bio medical waste

in the MCP Cards

.Stt"!,IrT'. R-ord lMaintenanll: ;.,l:.q.. .?i": .:-..-.-.. ,. : " i -.: :. ..

:,n" ..- :: - . :+ a+r

6PD Register of each doctor

including specialists

Li d littlrrg "t'

s"verelY anaem ic

R3 and R4

l1

A-

]I

Security services

Driver services

Apfipt'tat. dt"g ttorage facilities such as

Cri""*.e Redt*sal mechanisms

Tally lmplemented

Section XIIIAdditional

SCctio

fl"*".t Addttional ipegialty :Unit -

Trauma unit

Hospital training centre

r3.6

t].7

ll3 | Burn Ward

R.t*tG"t*Eiphvtt*l lv handicapped

Sec .il,l

SriNo ''- Namdofmedtinf ' r:l j- r'tt__i__;

t4. I l) Diet committee,l '', 2) [nt'ection control commtttee

3) Death audit -4 I Transtusion commlttee

5l Clinical meeting

4.3

4A4.5

4.6 @oth"rhosPituls4.7

4.8

4.9 9) Maternal death review commtnee

',:l:'

Secttion,X-: -- - - - - -- - --- - -- - - - -

Sr No r)rr2rlerlv medlcal cnecKup ur slrtPtwfv""

-N,,-h.r

ol fbod samples to FDA-I5.l@r.soffii.tDi.t ,-t,urt disPlayed in kitchen

I 5.:I 5.-j

I 5.4 niet teslrnp Keqlster avallaurs

wfif,I k't"fi *ctstered under The food Safety &

s,*auia Act 2006;ith registration number or licenseI ).)

n X\/iCri;ic"i:i"'r!Iffil'E:M

Sr 'No'16. I OPD

6.2

6.3 Maior Surgeries

6.4 Minor Surgeries

6.5 Deliveries

6.6 LSCS

t6.7 Lab investigations

r 6.8 X - Rays

r6.9 CT Scan Exams

16. l0 Sonographiej;

l6. r I MLCs

16.12 Post Mortems

6. J Dog bite cases

6 + Deaths due to Rabies

6 5 Snake bites

6 6 Deaths due to Snake bitesA 7 Scorpion sting

6. 8 Deaths due to Scorpion stine

'?-l

Sectior{..XVIf,.i,t -.,, :,.1 ''.- ..' ,:,.-',,i.,;,ii.'.i ,tj.,i.,,1,i.;,.,,;,

Impo'rtant indicatoryalues of tastm'dnttr.lri,tar: :'l : r :., :.

) trt-'5

\r--r

il\-t (tq..6-f- r\ -s:.ssiA.. $+\ \&*\:i.J

7o of Deliveries to IPD

% of LSCS to deliveries

% of MIS

Cash book wheth6iuplolatElWhethercashbookveffi

PLA cash book availabG and maliGined

After verificatioofDHS.

9.1 Whetherpostmgrtemffi9.2 Record room9.3 Mourner room9.4 ooctof sloom withlEiitreO toi tet9.5 lnfection controt protocoGEttoweO or not9.6 wtrettre@9.7 Yhether functional mortuary cibinetivii 6EiE

-'':'.. .::::=:-'::-::,' -:.a :; ' . -.- -:.:.,.:r-:'iiir.::::,i;;1..,;._:. , ; :t:i:.,.;:

Xli,fIOf Ar.i.'' :''.' ;::;:tt;;,r;;,i;fi.a;;;', ..: :rii;i

Whether

notC(Non transplant organ@

<.sr-r<="rn-t:+<q<E \\s\Er+S:_*a\

*\ a- j- \a=-r,.r-\

Section XXItr: Previou-s supervisory.

Note: E .rare lhat necessat! correctire ,neeilre,t are highlighted and iJ'possible, action taken on the spoL The

,\.lonthlt, t.eporl tf' monitoring visits und action poinls must be submitted to the appropriate authority tor

upltxrcling on Stute I'lolll ll' wehsite

To be filled by monitor(s) at the end of activity

Signature of Inspecting officer Signature of CS/MS

PHC lnspection Form

--u

E -:.-'.-a6l//

i'RII!'iARY I{EAX.-[H CENTER: INSPECTIO1Y I'ORMAT

I, GENERAL INF'ORMATION

Name of tl're Priman'health center ........

Taluka District

i\umber Of sub centers Nunrber olyfllqgqll4:i 7 PHC (Yesilrlo) IPHS PU_Q_(Ys!Al9l__RKS Formed (Yes/lrlo) RKS registerecl ( Yes/[rlo)

itv of RI(S Meetinss (Total meeting in the year 201 5- 16

Executive committee

meetings

Governing board meetings

TI. CONSTRUCTION

A. Vlain Building

/-\' Own building / other (Specify). .. ..:.. .

ln Case of no. building tbr PHC

a. Land available : Yes / No

b. Construction in Progress : Yes / No

c. Any Problems related to construction

d. Any repairs required for PHC :

e. If yes, give particulars

Yes / No

f. Efforts made to make available land for construction

g. Rarnp constructed :

h. Any Legal Matter

Yes / No

B. Quartersa- Availability of quarters for staff :

b. if yes, give number of quarters available:

c. If quarters not available

1. Land available :

2. Construction in progress :

3. Any problems related to construction / legal

Yes / No

Other:

Yes / No

Yes / No

Fartic ular R.ernarksNo.

1n r."

" t;."." nr r tcide PHC

2 C leanliness inside PHC

-) eoardJaisptayea in OPD about timing,

"--,i^e< r o? 1 n4 108 available etc

Biometricni"^1.r, ^f n^nthlv wnrk nlan

4

5

6 Condition of fumiture, curtains etc'

1 Trrbelighilf*t t. OPD, ward, labour

rotrm : adequate & working with

attached toilets / washrooms / Hand

wash

8 Disp@lauachedcopy)

9

UX. GEI{ER,AL ASPECTS

IV. BASIC FACILITIES AVAILABLE

Finlionul LuondryAVashing

Services

Mtl"ttttty & *-kt.g.""dition where applicable

/ Status (Ditails about any problem is to be

Water supply to PHC

Dii-ni.ing *"ter in oPD / ward

Telephone

Generator / Inverter

Solar Water Heater SYstem

Elbow TaP

t{anA*ashirlg facilitY in each with

soap to cleaned toilets with running

water facility.

-tr:riiat'iirt) oi dierary sen tcesi

Facility

--f 1)

V. T{{'MAN RtrSOURCES

A" Regular posts

St"Virg iIHQ i'l'es iNo)

f *,i#;sB8ivroc I sllA iNSSK / 1VCD /

PPIUCD /Tuhecto

B: Contractual posts

VI. OTTTER FACILITIES

(Give information about availability, working condition, cleanliness, repairs if an.v r6quired etc)

Designation Number of posts

Medical OfficersHealth Assistant {MHealth Assistant

No. Designation Number of posts Staying at HQ(Yes / No)Sanctioned Filled Vacant

i Staff nurse t

2 .{NIvl at sub centersa1 Other (Specifv)

No. Particular Remarks1 Operation Theater2 Labour room -

f\ Plastic curtains

B Labour table with foammattress.

C Colour coding of BMWD Patient examination traVs

E Protocols

F Revolving stoolG Fumigation

1 Separate Labour roomtla MO room

A Examination table withcurtains

B Examination tray

CT-Hand wash facilit

5 Laboratory

6 Nledical store

7 Ward (ltzlale/Female

separate)

8 Toilets (clean with adequate

running water suPPlY)

v{[. MAJOR & ivlINOR EQUIPVIENTS / SETS

No.

I

Equipments Available (Yes / No) If available,

functioning or not

PDA

2

)

Qtoth

ENT examination sgt ,

I Torch

5 Thernrometer

6 Hemoglobin meter

7 ILR

8n--^ tr

Oxygen cylinder9

10 S,r.tbn machine foot operated

-n.rus. itutio n t i(errrUuUag,o-'lntranheq{ tr rhec etc

11

12 IUD _Tubectomyi3

14 Vo..ctnrnv qet If available

15 MTP set MVA16 lVgfghirg *"chi."17 Radiant warrner

18tr^t- \l/amcr tnr.rrel t

lv Needle Cutter

VIII. PERFORMANCE

Durins month ProgressiveNo. Performance

1 OPD

Z IPD

Deliveries / Referred

4 Sterilization (TubectomY,

VasectomY)

5(Planerl & F{eld')

6 MTP / MVA

17 Immunization schedule,

E'?r)

{X. STOCK OF TMPORTANT I!{EDICINES

IConductec! sessioirs tiillyimmunizati on ?'0. \

oo r\{DRo II,{Rr0

iT

IyJCTS entry on percenta_ee ofwonlen registered in the firsttrimester

RTYSTI Treatecl1a

_Allcl legistration

No. Medicinc Present stock1

2-I Tab Paracetamol

i I ab septran1J Tab ciproiloxacintl- Tab cholroquine5 ORS

5 IV Ringer Lactate1 Inj. ASVa

!nL.qnV9 Other vaccines

a\

X. COMPLETENESS OF IIUPORTANT REGISTERS

No. Name of register Remarks1 Nluster roll2 Movement registera1 R3

I R4

_5 Lasn oooK

6 Dead Stock register7 Daily tabler register8 Medicine Stock register9 Expiry date register10 Master File1l Visir Bookt2 Biometric

13 RCH Registers

t4 Wqrk plan availabie MO/ANMl5 rru reglsters / partograph

16 Payment under JSy

XI. Quality paramet,er of the facilify

No. Essential Skill set R.,ernarks (Yes / No)

I klanage high risk pregnancY

2 Provide essential newborn

3care(thermoregulation, breastfeeding

and a sep s isl

) Manage sick neonates and infants

4 Co rrectly Uses PartograPh

5 Co rrectly insert IUCD

6 Co rre ctly administer vaccines'1 Alternate Vaccine DeliverY (AVDJ

syste m lu nctio nal

8 Segregation of waste in colour coded

9 Adherence to IN'IEP p ro tocols

No. Particulars Remarks

I Vector Bonne Disease

Surveillance Frogram

Malaria clinic functioned / DaYs

B MF registers

C BS taken in last quarter

D BS Positive

2 Waterborne Disease

Epidemic prone villages

B Action plans prepared

c

D

Epidemics in last 3 Years

Water / TCL samPle sent

(Quarterly)

3

A

Leprosy

Leprosy patients identifi ed

B

e

Nolt tewiOta Patients under PX

NIB

D

4

PB

Blindness progranc.

A No. of Cataract care done.

xII. OTI{ER DISEASE SURVEILLANCE PROGRAMS.

,-

XtrV. EXPENDITURE

B'.rdget

)(V. MIS

Whether regular data entry is done in web based MIS:

Any other important observation:

-1-1l

Sub Center'

Yes i No

;{xI{. gEC DISPLAY

l=rlo.

I

h{ateriai il.emarksApproach roads have directions to the healtlrfacility

2 Citizen Charter

Tirnings of the Health Facility.1a List oi services available

) Essential Drug List6 Protocol Poster.s

7 jSSK entitlemenrs

8 Immunization Schedule

9 ISY entitlements10 Other related IEC material

Plimaiy Health Center

POL / Repairs

Suggestions given for improvement:

Date of previous inspection

Actions taken on pervious suggestions given

Name & Signature of Officer

irto.

Received Expendi Received ExpenditureI OE

2,11 AMG4 RKS funds

5 Untied fund

Date of visit & inspection