MMSR-01 (2021)

MINIMUM MEDICAL STANDARDS REQUIREMENTS (MMSR) AUDIT & COMPLIANCE REVIEW REPORT

Date of visit: 8-Aug-24 CLINIC CONTRACT: Full Service ( ) Partial Service (X)

Auditor: Dr. Ibrahim Sakr / Jose B. Dipon Clinic: AL GIHAZ Clinic location: AL QADIYAH - ABQAIQ

Company : AL GIHAZ

Clinic Type: NOC (X) or POC ( ) Clinic start date): SEPT. 2021

Nurse / Physician name & contact # Mr. Gokilan Gunasekar 055 480 6825 / Mr. Mohammed Mahmoud

HCP name: Fajer Al Dammam Medical Center

Proponent Safety Advisor / Contact details:

Contractor Company Safety Advisor / Contact details: Mr. Suresh Kumar 056 461 4602

Work site / Camp Population: 1500

Daily census ( approx): 5 to 6

Contracted DF for Referral & Transfers:

Abqaiq General Hospital 013 566 2222

OTHER INFORMATION / REMARKS:

LEGEND: M=MMSR Manual. MOH=Ministry of Health. CFHS= Saudi Council For Health Specialties. CSM = Safety Construction Manual. CSAR= Construction Safety Administrative Requirements.
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 1: Building Requirements

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
1.1 The building has adequate space that satisfy patient flow &
functional needs. It provides easy access for stretcher cases
2
to ER area/ treatment room. Clinic Layout complies with
MMSR manual.
1.2 Floor covered with non-slip vinyl flooring. Seamless vinyl
flooring. No carpet acceptable 1 Some areas were worn out.

1.3 Walls, Cupboard units ( floor or wall mounted) for storage

must be non-absorbent/ laminate finish. 2 Advised to add wall mounted cupboards.

1.4 Fire rated doors 2

1.5 Emergency exit(s) and exit signs 2
1.6 Patient bathroom One bathroom was available. The flooring
1
was worn out.
1.7 Privacy for patient ( bed screen ) 2
1.8 Sinks are available in treatment/ examination areas and
bathrooms. 1 Sink was available in toilet area only.

1.9 Telephone (land line or dedicated mobile) 0 Not functional.

1.10 Desk and Examination table/ stretcher 2 No paper roll cover.
1.11 Dust tight medical supply cabinet 2
1.12 Air conditioning. Split A/C units recommended 2 Split Type AC
1.13 Facility is illuminated inside & outside/ Adequate lighting.
Intensity light in exam & treatment area 2
1.14 Emergency lights are strategically placed in case of power
2
failure
1.15 Sufficient power outlets. Multiple power cords are not
2
acceptable.
1.16 Clinic signs inside – including all rooms & areas within facility The clinic does not have a metal flag / sign
and facility directional signs outside. 1 board placed on top of its roof on each end.
1.17 Staff whereabouts signage is posted at the clinic entrance to
indicate :
• Hours of operation 1 Nurses information need to be updated.
• Staff contact details including regular& emergency contact
Numbers
1.18 Ambulance bay available. 2

1.19 Entrance ramp available for stretcher and wheelchair cases 2

LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(38): 31 0

PERCENTAGE: 81.6% 0.0%

GENERAL REMARKS:
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 2: Staff Qualifications, Competency skills and CMEs

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
2.1 There is documentary evidence (CC data base) that all Contractor &
subcontractors employees are medicaly insured with eligibility for First 2 c/o contractor company
Aid, Emergency care, investigations& access to in-patient care
2.2 Certified medical staff (doctor or nurse) are on duty at all times during
Nurse 1: MOH 1447/08/05, SCFHS
working hours. All medical staff shall be registered by Saudi
2 23-01-26. Nurse 2: MOH 1447/11/22,
Commission for Health Specialties (SCFHS) and licensed by Ministry
SCFHS 08-05-26
of Health (MOH)
2.3 Approvals of all CVs for the healthcare candidates by JHAH / MMSR
2
team prior to deployment at SA remote industrial Clinics.
2.4 Clinic Staff & Operations under the supervision of a senior medical
staff from same HCP, such as a Nursing Supervisor/ Trainer/OJT or a 2
Physician.
2.5 All staff (Physicians, Nurses, Drivers) shall have a valid BLS/ AED
certificate. The BLS, CPR/ FA certificate are issued by a recognised 2
Saudi Heart Association/SHA or AHA training centers.
2.6 Current Mandatory training; there should be supporting documents
kept in the employees’ personnel portfolio for all completed 2
educational courses, CMEs and Emergency skill competencies.
The support document is available and includes the following:
2.7 Valid First Aid certificate 2
2.8 Infection Control/ yearly 2
2.9 Fire Safety/ yearly 2
2.10. Airway management and Suctioning 2
2.11 Emergency/Disaster Response Preparedness including TRIAGE
2
training.
2.12 Drug familiarization program. Knowledge of commonly used drugs,
indications, side effects, contra-indications, adverse reactions. Safety 2
in storage, administration & dispensing.
2.13 IV therapy administration 2
2.14 Management of anaphylactic shock ( allergic reaction) 2
2.15 Chest pain management. A written protocol must be in place 2
2.16 Medical staff are capable of handling all types of emergencies, and
2
they are competent in operating all availbale emergency equipment
2.17 Work schedule shall cover 24/7 operation or as required for company
2
operational needs.
2.18 Staff must have at least one day off/week. This can be accumulative 2
2.19 The company has a staff -relief system covering staff for planned &
2
unplanned absences & on-call
2.20 Medical staff have access to reference/ education materials to keep Some books were not available like:
them current with clinical standards and practices and with their Nursing Practice, Emergency Care,
1 Anatomy and Physiology, Clinical
professional/ education requirements.
Practice, BLS and Trauma.
2.21 Staff completed their New Hire Orientation (NHO) program, with
2
support documents for General and Specific Orientations.
2.00

TOTAL SCORE(42): 41 0

PERCENTAGE: 97.6% 0.0%

GENERAL REMARKS:
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 3: MEDICAL EQUIPMENT& SUPPLIES

08-08-24
Code Minimum Standard Requirements Score F-Up #1 Comments / Recommendations
HCP ensures that their Clinic depending on category and
operational needs has adequate quantity of medical equipment,
at minimum includes, but is not limited to:
a. Bag valve mask (BVM), disposable.
3.1 2
b. Pocket mask with oxygen nipple/ inlet.
3.2 Sphygmomanometer, aneroid type, desk top or wall mounted, The connecting tube of the wall mounted BP
1 app was damaged.
and Stethoscope.
3.3 Crash Cart. Refer to FIGURE 3-2 and 3-3 The medications like Epinephrine 1:10000 and
a. Physician operated Clinic Crash Cart. Amiodarone were nearly expire on Oct. 2024.
1 Advised to replace the Nitroglycerin tablet 2.6
b. Large Nurse operated Clinic Crash Cart.
mg to 0.4 or 0.5 mg tablet.
3.4 Automated external defibrillator (AED) , portable with
monitoring capabilities as the followings:
a. Continuous Cardiac Monitoring.
b. Able to print strip. The available AED does not have monitoring
1
c. Blood pressure measurement. capabilities. No spare pads and batteries as well.
d. Oxygen saturation measurement. PSO2 monitoring
Separate pulse oximeter is acceptable
3.5 Suction: portable suction, with rechargeable batteries. 2
3.6 Infusion pump, Intravenous (IV) pole/stand, mobile. 2
3.7 Exam/emergency bed/ stretcher with rails& lockable wheels.
(Stretcher without wheels acceptable at single room clinic). 1 The available bed/stretcher does not have rails.

3.8 a.Backboard, long with straps.

b. Scoop stretcher with straps.
c. Stretcher, basket. (In single room facility, to be part of
operation emergency response supplies) The straps for the long back board were not
1
available.
d. Stretcher
emergency, disposable {(e.g., Life & lite emergency), five (5)
per box} . e.
Hare tractionresponse
3.9 Emergency unit. bag. Not available at the time of inspection. It was in
For information on contents& checklist refer to FIG. 3-4 n/a
the ambulance at the site.
3. 10 Refrigerators dedicated as the followings:
a. For staff (food & drinks) 2
b. For chilled items/ drugs.
3.11 Ophthalmoscope/otoscope, wall mounted. 2
3.12 Oxygen Resuscitation unit. Not available at the time of inspection. It was in
n/a
the ambulance at the site.
3.13 O2 cylinders, different sizes as needed; wall secured or cart. Size G: 1ea, Size E: 1ea, Size D: 2ea were
2 available. Advised to request additional 2ea size
D.
3.14 Entonox/ Nitronox unit, portable. 2 3ea units, 1ea cylinder were available.
3.15 Weight/ Height scale. 2
3.16 Emergency eye irrigation unit. 2

3.17 Sharps disposable box for disposal of contaminated sharp.

2

3.18 Glucometer portable. 2

 The HCP ensures that the medical facilities depending on
category and operational needs have adequate quantity of
standard medical supplies at a minimum include:
3.19 For Medical Supplies sample list, Refer to FIGURE 3-5 Some of the items were not available. Advised
1 to provide an updated list to track.
3.20 For Linen Supplies (disposable). Refer to FIGURE 3-6 1 Not available. Advised to provide a checklist.

3.21 For Stationary (Office Supplies). Refer to FIGURE 3-7 1 Printer not available.

LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(42): 30 0

PERCENTAGE: 71.4% 0.0%

GENERAL REMARKS:
 MMSR AUDIT & COMPLIANCE REVIEW REPORT
STANDARD # 4: PHARMACEUTICAL SERVICES
08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
4.1 HCP shall ensure that their facilities have a drug formulary
with a wide spectrum of drugs. At a minimum, this shall 2
include all the categories listed in the MMSR Manual.
4.2 Drug formulary list is determined and approved by the
responsible physician. Selection of drugs and quantities for
2
each DRUG CATEGORY depends on the operational needs
for the facility. For clinic formulary, Refer to FIGURE 4-1.
DRUG ADMINISTRATION:The HCP shall ensure that their
medical facilities have a drug dispensing guideline s (written
in a clear format) for nurses who are authorized to administer
and dispense certain drugs in the absence of a physician and
at a minimum it includes the followings:
4.3 A list of all medications/drugs that clearly stipulate which
medications can be administered by the nurse as standing
2
order (SO) , or require a physician’s consultation telephone
order (TO).
4.4 Written Standing order guidelines for nurses.
For more information, Refer to FIGURE 4-3 Page 96 2
4.5 Specific procedures to be followed for all TO, including
documentation process. 2
4.6 There is evidence that the nurse successfully completed a
drug familiarization competency program. 2
4.7 There is a drug information reference system available on-site
or remotely (e.g. pharmacology book; online drug information
site; physician/ pharmacist consultation; drug inserts file). 2 MIMS was available.
 DRUG DISPENSING: The HCP shall ensure that their
medical facilities dispense all medications/drugs as follows:
4.8 In a suitable container. 0 Not available.
Labeled with the following information:
4.9 Patient’s name and ID number. 0 Not available.
4. 10 Drug’s name, strength and Date. 0 Not available.
4. 11 Dispensing instructions/e.g. 1 tablet 3X /day after meals 0 Not available.
DRUG STORAGE: The HCP shall ensure that their medical
facilities have an adequate storage and inventory control
system with appropriate checklists in place to facilitate the
dispensing and inventory control of all medications/ drugs in
stock, as follows:
4.12 Ensure that all listed drugs/medications are available&
Current. 1 Medicines inventory was not updated.
4.13 Minimum Stock Levels (MSL) are maintained at all times. Not enough for 3 months. Some of the
1 medicines were not available as per drug
formulary list.
4.14
2
Medication are Rotated (arrange shorter expiry date in front).
4.15 Inventory/expiration check date is conducted on monthly
basis. Log is available upon request. 0 Medicines inventory was not updated.
All medications/drugs shall be stored according to
manufacturer's recommendations, as follows:
4.16 In an air conditioned room. 2
4.17 2
On shelves above floor level or in a lockable cupboard.
4.18 Appropriately organized and identified in a systematic way
2
(alphabetic order or drug group).
4.19 2
Oral and external use medications are stored separately.
4.20 N/A
Narcotics/Controlled drugs are stored under double lock.
4.21 Sensitive to heat drugs are stored in a dedicated medication
fridge. 2

DRUG DISPOSAL: The HCP shall ensure that their medical

facilities have a system in place for the safe disposal of
expired medications/ drugs and it is implemented as follows:

4.22 Expired medications are placed into a seperate box.

2
4.23 Box is labeled "EXPIRED" 2
4.24 Stored separately from other medications/drugs. 2
4.25 There is evidence that expired medications/drugs were sent to
supplier for proper disposal that meets MOH regulations. 2 Last waste disposal on June 2024.
Documentation is available upon request.
4.26 The HCP shall ensure that their medical facilities’ staff is N/A
familiar with and adhere to MOH regulations in regards to
transportation, dispensing, administration and disposal of
Narcotics/Controlled substances, where applicable .

TOTAL SCORE(52): 36 0

PERCENTAGE: 72.0% 0.0%

GENERAL REMARKS:

Some ACLS drugs like Dextrose 50%, Lidocaine 2%, Nitroglycerin 0.4 mg tablet and Epi 1:10000 were not available. Advised to
request alternative for Epi 1:10000 to 1:1000 ampoule.
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 5: DISASTER RESPONSE PREPAREDNESS

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
5.1 The Medical facility has a quick reference Medical Emergency HCP ERP was available. However, for the
and Disaster Response plan (DRP) available. 1
contractor was not available.
5.2 There is a DRP in place and it is strategically displayed Advised to display in Nursing station once
0
prominantly at the nursing station/ safety notice board. the DRP/ERP is available.
5.3 The plan/ DRP outlines how chain is activated (e.g., ring-
down-system flow chart). 2

5.4 Names and Contact numbers for First Aid Trained

employees, list updated and displayed. 0 Not available.

5.5 Nearest Medical Designated Hospital/ MDFs name and

contact number is clearly posted as the first responder and Abqaiq General Hospital 013 566 2222 (10
2
where assistance may be requested & casualties taken. kms)

5.6 Medical facility must be provided with an appropriate and

dedicated communication device with the right frequency
in line with its company’s safety/ Emergency Response 0 Not available.
Policies/ Procedures. (Mobile GSM, Thuraya etc.)
 5.7 The DRP list contains a 24 hour contact numbers for
emergency and key personnel to facilitate proper/ timely
response in the event of medical emergencies, disasters,
transfers and Medivacs. List includes the following Tel # :
2
1. Contractor Company & S.Aramco Security Operation.
2. Police & Red Crescent. 3.
Nearest healthcare facilities, MDFs including MOH hospitals.
4. On-call company representative or alternate (construction
Manager / Admin Manager/Health or Safety Advisor).
5. Evacuation
5.8 The medical group leader,
facilities have where applicable.
Disaster Bag (s) available: (each
bag for 5 or 2 victims) Refer to Figure 5-1 and Fig. 5-2 2

5.9 Each Emergency Response Bag has the required medical Not available at the time of inspection. It was in
supplies. For the contents of ER Bag: Refer to Figure 3-4 n/a
the ambulance at the site.
5. 10 The medical facilities emergency response bag(s) and
Disaster Bags are appropriately checked on monthly basis
with Evidence of completion is available upon request. 2 Checklists were available.

5. 11 ROLE CARDs: Role of each medical personnel is clearly

defined on role cards and carried by the staff in the event of 0 Not available.
medical emergency and disaster response.
5. 12 Completion of training both theoretical and practical is
documented on the staff’s training record. Evidence is 2
available upon request.
5.13 Training includes the application of a commonly used triage
system/ Algorithm in disaster management such as:
• S.T.A.R.T. 2 SALT
• M.A.S.S.
• SALT
5.14 Training is conducted yearly. Evidence of completion is
available upon request. 2
5.15 Staff takes part in at least two (2) disaster drills a year. 0 Waiting for the contractor to conduct.
5.16 The medical facilities have an approved emergency response HCP ERP was available. However, for the
protocol in place. 1 contractor was not available.
5.17 There is evidence that all staff are trained and oriented on
disaster response procedures. 2

5.18 Staff shows/verbalizes location of disaster response plan and

disaster call-out list of key personnel. 2
LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(36): 22 0

PERCENTAGE: 61.1% 0.0%

GENERAL REMARKS:
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 6: AMBULANCE SERVICES

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
6.1 The medical facilities make arrangements to provide, a
dedicated emergency AMBULANCE vehicle to transport the
sick and injured to a hospital facility for further management.
6.2 AMBULANCE is a two-wheel or four-wheel (2WD/4WD) drive
vehicle depending on location and terrain condition (e.g.,
tracks, dirt roads, etc.). 4x4 WD is recommended for all off
road areas.
AMBULANCE vehicle specifications is provided at a minimum
with the followings: Refer to Figure 6-1
6.3 Proper warning flashlights& Siren

6.4 Purpose markings as: AMBULANCE signs and Red Crescent

Insignia painted on the outside.
6.5 Air conditioning unit in the patient compartment.
6.6 Fire extinguisher ABC, small type.
6.7 Appropriate communication device (radio, cellular and/or
satellite phone) with available network and frequency.
Ambulance essential medical emergency and resuscitation
supplies include: The items marked with an *asterisk, are
loaded-up at the time of dispatch.
6.8 *Emergency Response Bag.
6.9 *Automated External Defibrillator (AED).
6.10 *Suction machine (portable) with catheters and tubings
6.11 *Portable oxygen resuscitation unit (Robert Shaw unit or other).
6.12 *Entonox/ Nitronox unit
6.13 Stretcher collapsible (Ferno or other). & blankets
6.14 Backboards long and short with straps.
6.15 Oxygen cylinder with O2 supplies accessories.
6.16 First Aid kit/ supplies.

6.17 IC& Personal Protective Equipment (PPE) items such as:

Goggles, Surgical mask, Plastic apron. Examination gloves
(sterile+ unsterile), Small sharps container, Infectious waste
plastic bag, Plastic trash bag, Heavy duty gloves, Safety hard
hat Safety shoes.
6.18 AMBULANCE equipment and supplies are checked daily or
after each patient trip by HCP. Inspections are recorded and
available upon request. Refer to Figure 6-2
6.19 The AMBULANCE is taken for a test run on a daily basis. The
vehicle condition is checked and recorded and available upon
request.
6.20 The AMBULANCE is thoroughly cleaned inside and outside
on a weekly basis or after a patient run & the AMBULANCE
Movement Log is completed.
6.21 The AMBULANCE (s) have valid (quarterly) PM checks/
Preventive Maintenance and the required Government
Periodic Inspection, with support documentation evidence is
available upon request.
6.22 AMBULANCE is covered with valid Comprehensive Insurance
and valid registration.
6.23 The VEHICLE REGISTRATION card (Isthimara) indicates
that the used vehicle is registered as an AMBULANCE.
6.24 Ambulance Statistics form is completed at the end of each
month.
6.25 Ambulance driver completed orientation and OJT training
program to ensure site familiarization, their role &
responsibilities. The Ambulance driver knows the location and
route to all nearby MDF/ medical designated facilities.

LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(50): 0 0

PERCENTAGE: 0.0% 0.0%

GENERAL REMARKS:

The ambulance was not available at the time of inspection. It was on the site.
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 7: EOC & SAFETY

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
FIRE SAFETY: The CC shall ensure that their medical
facilities have fire safety equipment and Fire safety protocole
in place that includes:
7.1 Appropriate fire extinguishers (A, B, C) placed in strategic
2
locations.Labeled with monthly periodic inspection.
7.2 Staff shows location of the nearest fire alarm and type of
2
available fire extinguishers.
7.3 All staff are oriented on fire safety able to verbalize what to do
2
in the event of fire (R.A.C.E. and P.A.S.S.).
7.4 Functional smoke detectors installed. 2
7.5 Staff knows/verbalizes the proper fire evacuation in the event
2
of a fire
7.6 Fire evacuation procedure is posted in strategic location
0 Not available.

EYE WASH& DECONTAMINATION SHOWERS: CC ensures

that their medical facilities have eyewash station available as
follows:
7.7 Portable eye wash is acceptable for one Nurse operated
2
facility “level C and D”.
7.8 Fixed unit is placed outside the facility building in a sheltered
area , and maintained in proper working order. n/a

7.9 Water is maintained at a tepid temperature and the unit is in

n/a
operational status.
7. 10 There is evidence that unit is regularly tested/inspected.
n/a

HAZARDOUS SUBSTANCES SAFETY: HCP ensures that

their medical facilities have a system in place for the safe
management/ storage of hazardous substances as follows;
7.11 Material Safety Data Sheet (MSDS) Manual available. 2
7.12 Manual is placed on a strategic location, easy to locate
2
quickly by clinic staff.
7.13 Current MSDS for each hazardous substances/ products used.
2

7.14 Facility has appropriate antidotes for handling chemical

2
exposure.
COMPRESSED GAS CYLINDERS: HCP ensures the
following safety regulations are observed when storing,
handling, and using compressed gas cylinders:
7.15 Pressure is checked and logged daily, log sheet available. 2
7.16 O2 Cylinders are replaced when content reaches 500 PSI. 2ea Oxygen cylinders SN:AS2748231 & SN:
Hydro test to be completed and current. 1 AR0693294 and 1ea Entonox SN: ISO7866 were
not hydro tested.
7.17 Cylinders are securely stored on oxygen delivery carts, walls,
or in a secure storage cage. 2

7.18 Cylinders kept in an upright position (valve end up), on a level

floor, well ventilated and dry storage area 2

7.19 Storage room free from flammable substances (i.e., oil and/or 2
volatile liquids).Away from direct sunlight and from other
sources of heat as cylinder temperatures must not exceed 50
°C (122 °F).
7.20 Sources of ignition (i.e., motors, generators, communication 2
systems, etc.) are removed from the O2 storage room.
7.21 Empty cylinders are marked empty& stored separate from full 2 2ea Entonox cylinders and 1ea Oxygen cylinder
cylinders. were empty at the time of inspection.
7.22 No smoking signs are available and posted in areas where 2
gas cylinders are located.
ELECTRICAL EQUIPMENT SAFETY: the following general
precautions and safety regulations are observed by HCP and
CC when handling electrical equipment
7.23 All electrical equipment are kept in working condition and safe 2
for use; do not tingle, shock, spark or get overheated.
7.24 Case or body of the item is not cracked, chipped or broken. 2
There are no exposed internal parts.
7.25 The controls (buttons) are complete and functional.There is 2
an OFF switch: when used, equipment turns OFF.
7.26 Unit’s cord and plug are not damaged, cord has no cracks or 2
breaks. Plug is directly secured to wall socket.
7.27 There is evidence that equipment is periodically checked for 2
obvious defects or hazards.
7.28 There is evidence that defective equipment is removed from 2
service, has tags so that no other staff will attempt to use it.
7.29 All electrical equipment are ground protected. 2

MEDICAL EQUIPMENT SAFETY: Precautions and safety

regulations are implemented by the operating HCP to ensure
that the medical devices meet appropriate standards of
safety, quality and performance as the followings:
7.30 There is a process in place for maintenance/ service/ 2
acceptance test of medical equipment performed/ arranged
by the HCP.

7.31 All patient care equipment must undergo periodic preventive

maintenance (PM) checks. This includes calibration& testing
as per manufacturer and local policy. PM stickers or log are 2 Due on 24-Dec-2024.
placed to indicate PM completion and next due date.
7.32 There is evidence that there is a backup system in place for 2
repairing medical equipment.
7.33 All equipment are checked daily for normal function and 2
findings and recorded in a log. Log is available upon request.

LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(66): 57 0

PERCENTAGE: 86.4% 0.0%

GENERAL REMARKS:
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 8: INFECTION CONTROL& HOUSEKEEPING

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
8.1 VACCINATION: there is a Vaccination program
2
implemented for all open wound injuries.
8.2 Administered vaccines are appropriately logged in a book 2
8.3 STAFF HEALTH:There is evidence that screening and
immunization were completed as per MOH regulations for all
staff prior to site assignments, such as :CXR, PPD test, HIV, 2
Hepatitis B&C vaccine.
INFECTION CONTROL

8.4 The HCP ensures that staff knows and complies with the
2
standard precautions
8.5 Personal Protective Equipment (PPE) is always available. 2
8.6 STERILIZERS are not present at the remote industrial
medical facilities. The HCP shall ensure that all provided CSS n/a
supplies (instruments & packs) are disposable.
8.7 HAND WASHING: Wash basin/sink with hot & cold water is
1 Hot water was not available.
available in all Clinical areas.
8.8 Liquid soap & disposable single paper towel dispensers 1 Paper towel was not availabe.
8.9 Trash cans ( covered )& labeled. Does not have a cover. Advised to request
1
additional trash cans.
8. 10 The HCP shall ensure that their medical facilities have
2
approved alcohol-based hand-rub.
8. 11 Staff knows and is able to demonstrate appropriate hand
2
sanitizing/ Hand washing technique.
8. 12 Examination tables are protected with disposable cover
0 Not available.
sheets or paper rolls.
8. 13 The HCP ensures that appropriate bactericidal available and it
0 Not available.
is used to disinfect hard surfaces inside the clinic areas.
8. 14 Disposable linen stored in a protected clean area. 0 Not available.
8. 15 Soiled linen placed (deposited) into covered, leak proof bags,
0 Not available.
as per established criteria.
8. 16 Laboratory specimens are handled, stored and transported in
n/a
accordance with established policy/protocol.
DISPOSAL of WASTES & INFECTIOUS SUBSTANCES:
HCP has a system in place for disposal of contaminated
wastes and safe management of infectious wastes/
biomedical waste(identification, segregation, collection,
storage, transportation, treatment and disposal) , as follows:
8. 17 System is in compliance with Infection Control (IC) guidelines
2
and is in accordance with MOH regulations.
8. 18 Staff is familiar with& able to verbalize the disposal protocol
(i.e., all sharps boxes are securely taped shut, double boxed 2
and transported to an approved agent for disposal).
8. 19 Disposal of sharps: Wall mounted, puncture resistant, leak
proof containers are available. 2

8. 20 Sharp containersc are replaced when they are three quarters

2
(¾) full.
8. 21 There is no recapping of needles; Scoop method is followed
2
for recapping used needles.
8. 22 Clinic Staff and assigned Janitors are able to verbalize what Janitor was not available at the time of
2 inspection.
to do in the event of a needle stick/sharps injury.
8. 23 Color coded plastic liners shall be used in waste
receptacles. Yellow or Red= infectious/ contaminated 2
materials. Blue=general waste.
FRIDGE: The HCP & CC ensure that their medical facilities
have dedicated medication refrigerator available, as follows:
8. 24 There is a thermometer available in each refrigerator. 2
8. 25 Medication refrigerator is used for medications only. 2
8. 26 Temperature is maintained between 2-8 degrees Celsius
(36-46 degrees Fahrenheit). 2

8. 27 Refrigerator’s temperature is recorded twice a day in a log

2
sheet. Log is available upon request.
8. 28 g. Refrigerators are cleaned inside and out on a regular basis,
1 Advised to clean regularly.
and when applicable, defrosted as needed.
JANITORIAL SERVICES
8. 29 Janitor room is provided with storage facility & water supply
The room is kept a clean, organized and in safe condition. The Janitor's room needs to be organized and
Dedicated Janitor is scheduled part-time or full-time to the 1
cleaned regularly.
clinic "as needed" to provide housekeeping services.
8. 30 Clinic is cleaned at least once daily. This includes mopping of
floor, damp dusting, trash cans emptied twice daily& floor 1 The clinic needs to be cleaned regularly.
polished monthly. No accumulation of refuse or litter.
8. 31 The Janitor is provided with the necessary equipment &
supplies for cleaning the clinic, such as: blood spill kit, Cleaning materilas and supplies were not
1
antiseptic soap, hand soap, paper towels, toilet paper, enough.
disinfectants…etc
8. 32 The HCP shall ensure that their medical facilities have a
0 Advised to post.
procedure for cleaning blood spills and that it is posted.
8. 33 Janitors know/ verbalize the blood spill cleaning procedures The janitor was not available at the time of
and cleaning fluid dilution ratios, as per guidelines. n/a
inspection.
8. 34 The CC & HCP shall ensure that their medical facilities’ janitor
0 Not available.
attended an infection control training/ class.
8. 35 The CC & HCP shall ensure that their medical facilities’ janitor
receives training/orientation in medical housekeeping. On-site
orientation performed by a nurse and/or a senior janitor is 0 Not available.
acceptable. Evidence available upon request.
8. 36 The CC & HCP shall ensure that their medical facilities’ janitor
is appropriately immunized prior to assignment. Evidence of 0 Not available.
immunization is available upon request.
8. 37 The medical facilities’ lockers, cabinets and janitor closet are
0 Not available.
kept clean and tidy.
8. 38 The HCP ensures that their medical facilities’ cleaning agents
and disinfectants are appropriately labeled& stored. 0 Not labeled.

8. 39 The HCP ensures that the’ color coded mops are cleaned and
disinfected on a daily basis. Evidence is available. 0 Not available.

8.40 Trash bins/ paddled with cover are availble in all patient care Not covered. Advised to provide additional trash
areas. 0 bins.

8. 41 The HCP ensures that janitors use separate cleaning

equipment for toilet areas. This shall be in evidence. 0 Not available.

LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(82): 43 0

PERCENTAGE: 52.4% 0.0%

GENERAL REMARKS:
 MMSR AUDIT & COMPLIANCE REVIEW REPORT

STANDARD # 9: MEDICAL RECORDS , P&P

08-08-24 F-Up #1
Code Minimum Standard Requirements Score Score Comments / Recommendations
MEDICAL RECORS. The HCP shall ensure that:
9.1 Dedicated medical record/ file available for every patient, at
their medical facilities. Electronic filing recommended. 0 Not available. Advised to provide Electronic file.

9.2 Tetanus immunization record available in the patient’s

2
medical record/file.
9.3 Log book for documenting patient’s attendance is available.
Information listed kept for statistics purposes and periodic 2
report. Refer to Figure 9-1
9.4 A process in place for reporting patient Off-Duty status. 2
9.5 Printed education materials/ posters available. 2
9.6 The medical staff document each and every encounter into
2
the medical record.
REPORTING ON-THE-JOB/OFF-THE-JOB INJURIES
9.7 There is a system in place for reporting on-the-job/ off-the-job
injuries. Injuries shall be documented/ recorded in a log book
and reported as per established regulations of MOH, MOL 2
Law & Saudi Aramco LP. Refer to GI 6.0005

Health Care Policies, Procedures& GUIDELINES

9.8 Medical Staff have access and are familiar with the location
2
of their Health Care Policies, Procedures and Guidelines.
The HCP shall ensure that each medical facility has the
following Policies & Procedures developed:
9.9 Scope of Service: Has a policy that defines their scope of
service, such as:Type of offered care, eligibility of care, 2
treatment and investigations performed.
9.10 DRP and MEDIVAC: Policies and Procedures are in place
for: Medical Emergency Response, Disaster Response and 2
MEDIVAC procedure (as per GI 1321.015).
INFECTION CONTROL POLICIES AND PROCEDURES
9.11 Infection Control in Medical Facility Personnel. 2
9.12 Blood and Infectious Fluid Exposure. 2
9.13 Employee Screening and Immunization Program. 2
9.14 Hand Hygiene. 2
9.15 Cleaning of Blood Spills. 2
9.16 Needle sticks/Sharps injury. A written guideline is available for
2
staff to follow if such an event occure
9.17 Reporting Occupational Illness/ Communicable diseases (i.e.,
2
Hepatitis B/C, Tuberculosis, Chicken pox, etc.).
GENERAL POLICIES AND PROCEDURES
9.18 Waste Management. 2
9.19 Protocols for consultation and for patient referral to the
2
nearest hospital, or to an inpatient medical facility.
9.20 The HCP has a patient consultation, referral and transfer
policy to Saudi Aramco Remote Urgent Care Facilities and 2
referal to the Nearest MDF/ inpatient facility.
9.21 The HCP has a policy that describes a reliable alternative
2
system of transfer in place in the absence of an ambulance.
9.22 A policy on Occupational Health Services (physicals and
conservation program, i.e., hearing, pulmonary, etc.) is n/a
available for their employees.
SAFETY POLICIES AND PROCEDURES
9.23 Fire Drills and Fire Response. 2
9.24 Equipment Maintenance 2
9.25 Adherence to GI-150.002 (First Aid Training for Employees). 2
PATIENT CARE GUIDELINES (EXAMINATION AND
TREATMENT PROTOCOL FOR NURSES)
9.26 Protocols for the treatment of common illness and
emergencies, from common cold to chest pain, burns, etc. 2

9.27 Nursing Procedures and Work Practice.

2

9.28 Management of Death. 2

9.29 Patient and Family Rights. 2
9.30 Confidentiality of Patient Information.
2

9.31 Medication Guidelines: Requisition, administration,

2
Prescribing, dispensing, shipping, receiving and storing.
COMMUNICATIONS
9.32 Medical staff keep a communication book/file available to
2
maintain effective internal and external communication.
9.33 The medical facilities have a notice board(s) available and
2
that it contain current relevant information, e.g., safety,
9.34 CC & HCP ensure the medical facilities have the following
communication devices:Landline phone, fax machine, 0 Not available.
dedicated GSM, 110 or similar system.
LEGEND: SCORE : 0 = Nil 1= Partial 2= Complete NA= Not Applicable.

TOTAL SCORE(68): 62 0

PERCENTAGE: 91.2% 0.0%

GENERAL REMARKS: