Policy Guidelines on the Standards of Care for Older Persons in All Healthcare Settings

January 30, 2017

DOH ADMINISTRATIVE ORDER NO. 2017-0001

 

I. BACKGROUND

Life expectancy is increasing worldwide. According to the 2006 revision of the United Nations World Population Prospect Report for 2005-2006 the Life Expectancy at birth in the Philippines is 4.5 years higher than the world average of 67.2 years and is the 5th highest among Southeast Asian countries.

The increasing number of older Filipinos is the result of increasing life expectancy and reduction of fertility rate. Its implication in health care delivery has been recognized by the Government with the issuance of Republic Act (RA) No. 9994, the Expanded Senior's Citizens Act of 2010, which is an act granting additional benefits and privileges to senior citizens, further amending RA No. 7432, otherwise known as "An Act to Maximize the Contribution of Senior Citizens to Nation Building, Grant Benefits and Special Privileges and for other purposes".

RA 9994 Section 5.C on Health states that "The DOH, in coordination with local government units (LGUs), NGOs and POs for senior citizens, shall institute a national health program and shall provide an integrated health service for senior citizens . . . ." Throughout the country, there shall be established a "senior citizens' ward" in every government hospital. This geriatric ward shall be for the exclusive use for senior citizens who are in need of hospital confinement by reason of their health conditions. However, when urgency of public necessity purposes so require, such geriatric ward may be used for emergency purposes, after which, such "senior citizens' ward" shall be reverted to its nature as geriatric ward.

Full implementation of this R.A. needs the guidance and the availability of the National Standards on Patient Safety not only in hospitals or acute care setting but also in Long Term Care provision including that of nursing homes, community ambulatory and home care which constitute the whole continuum of care to address the special health needs of the Filipino Older Persons. ATICcS

II. OBJECTIVES

A. To provide policy guidelines for standards of care for older persons in all healthcare settings: acute and sub-acute care, rehabilitation facility, continuing care retirement community and long term care.

B. To identify the basic rights of older persons, providing them dignity, safety, and protection from exploitation and any form of abuse or neglect.

C. To provide a guideline to safe and secure environments for older persons in all settings of care.

D. To strengthen the collaborative efforts among various stakeholders engaged in the health service delivery for older persons to be accessible, of quality, more effective and efficient.

III. SCOPE

This Order shall cover the standards of care for older persons in acute care, sub-acute care, continuing care retirement community, rehabilitation and long term care facilities of government healthcare facilities in the Philippines.

IV. DEFINITION OF TERMS

A. Acute Care — care that is generally provided for a short period of time to treat a new illness or a flare-up of an existing condition. This type of care may include treatment at home, hospital or emergency department.

B. Comprehensive Geriatric Assessment (CGA) — a process which includes a multidimensional assessment of a person with increasing dependency, including medical, physical, functional, cognitive, pharmacotherapeutic status and social-environmental situation. May use standardized assessment instruments and an interdisciplinary team to support the process.

C. Community Based Care — The blend of health and social services provided to an individual or family in his/her place of residence for the purpose of promoting, maintaining or restoring health or minimizing the effects of illness and disability. These services are usually designed to help older people remain in the community. They can include home health care service, adult daycare, barangay health services and family support networks.

D. Complex Health Needs — serious or severe interrelated multiple health conditions [adapted from http://www.gov.scot/Publications/2007/01/18133419/4]

E. Decisional Capacity — an older person having four abilities: understanding, appreciation, reasoning and expression of choice. Understanding means that appropriately conveyed information is comprehended, retained long enough to be recalled in a discussion, and the relationships between interventions and outcomes are perceived. Appreciation involves the recognition of how appropriately conveyed information relates to a person's specific circumstance, and can make insights about the relative advantages and disadvantages of a proposed solution. Reasoning involves the manipulation of information to compare various alternatives and their consequences, and the justification of a rationale as a framework for such comparisons. Lastly, the expression of choice means the ability to communicate or convey a clear choice or decision. (Adapted from Hazzard's Geriatric Medicine and Gerontology Textbook, 6th edition) TIADCc

F. Frailty — a clinical state of being vulnerable to illness/es and having poor health outcome resulting from age associated decline in reserve and function causing a combination of problems with mobility, strength, fatigue, weight loss and reduced activity.

G. Frail older person — an older person needing of substantial level of care and support.

H. Geriatric Care — providing prioritized patient-centered care for the older person with complex health needs in all healthcare settings by optimizing function and/or well being, integrating goals and values of the patient and their family in their plan of care and coordinating healthcare and healthcare transitions with other healthcare providers. (adapted from American Geriatric Society (AGS) and Association of Directors of Geriatric Academic Programs' (ADGAP) Entrustable Professional Activities (EPAs) for geriatricians)

I. Home Health Care Service — refers to health or supportive care provided to the older person at home by licensed health care professionals to include, but not limited to, physicians, nurses, midwives, physical therapist, caregivers and barangay health workers. (adapted from RA 9994)

J. Long Term Care — A range of health care, personal care and social services provided to individuals who, due to frailty or level of physical or intellectual disability, are no longer able to live independently. Services may be provided in a person's home, in the community or in residential facilities (e.g., nursing homes or assisted living facilities).

K. Long Term Care Facilities — An establishment primarily engaged in providing inpatient nursing and rehabilitative services to individuals requiring long term care.

L. Multidisciplinary Team — Consists of members of different disciplines, involved in the same task (assessing people, setting goals and making care recommendations) and working alongside each other, but functioning independently.

M. Older Person — a person who is sixty (60) years old and above and is synonymous with the definition of senior citizens as described in RA 9994.

N. Quality of Life — The product of the interplay between social, health, economic and environmental conditions which affect human and social development. It is a broad-ranging concept, incorporating a person's physical health, psychological state, level of independence, social relationships, personal beliefs and relationship to salient features in the environment. As people age, their quality of life is largely determined by their ability to access needed resources and maintain autonomy and independence.

O. Rehabilitation facilities — provides services designed to improve function and/or prevent deterioration of functioning. Such services may include physical therapy, occupational therapy, and/or speech therapy.

P. Sub-acute Care — is a bridge between acute care and home care. It is medical and skilled nursing services provided to persons who are not in the acute phase of an illness but who require a level of care higher than that provided in a long-term care setting.

Q. Surrogate Decision Making — decisions made on a patient's behalf when the patient has lost decisional capacity.

R. Surrogate Decision Maker — a person who gives surrogate decision making, a proxy.

V. GENERAL GUIDELINES

A. The standards of care for the older persons shall follow the principles of Patient-Centered Care and Senior Friendly Environments as described in this Order.

B. The standards of care for the older persons shall be integrated in the DOH licensing standards, facility development plans, and PhilHealth accreditation standards for all healthcare facilities.

VI. SPECIFIC GUIDELINES

A. PATIENT CENTERED CARE

1. DIGNITY

The right of the older person to maintain integrity and self-respect to enjoy good quality of life and equity in access to the services necessary for optimal health must be ensured.

a. Processes should be respectful of older persons' values, cultural and religious belief.

b. The institution should respond to older persons' and families' request for spiritual and religious support.

c. Policies should ensure utmost respect, timeliness and appropriateness of response to older persons' need.

d. End of Life Care Policies should be in place, monitored and implemented.

2. PRIVACY

The state of being free from unsanctioned intrusion

a. There should be older persons' safeguard for ensuring privacy in all procedures, examinations and treatments.

b. There should be arrangements to ensure the patient's/resident's privacy with particular regard to personal self-care and discussions/conversation of sensitive information with patient and family.

3. INFORMED CHOICE

The process of choosing options to make acceptable healthcare decisions based on accurate information and knowledge between the healthcare provider and the older person or his surrogate decision maker.

a. The healthcare provider should inform the decision maker regarding goals of care strongly based on comprehensive geriatric assessment (CGA) and respectful of the patient's dignity.

b. Full-disclosure of available services, procedures and costs should be communicated and documented to the patient or surrogate decision maker for an informed decision. SDAaTC

c. Information on alternative sources of care and services should be provided when healthcare facility cannot provide the care and services.

d. All information should be clearly stated in a manner that is culturally sensitive and understandable to the decision maker.

e. Proper documentation of the procedural consent and advanced directives of the patient/surrogate decision maker and care plan should be stated.

4. CONFIDENTIALITY

Privacy in the context of privileged communication (such as patient-doctor consultations) and medical records are safeguarded.

a. The healthcare facility respects that older person's health information is strictly confidential.

b. The care provider and patient or surrogate decision maker must accompany and enforce a confidentiality agreement.

c. Policy and procedures to prevent loss or misuse of patient information are in place and implemented.

d. The older person or surrogate decision maker is consulted for disclosure on what information is provided to his/her relatives or representative in relation to his/her care and to whom this is provided.

5. PROMOTION OF QUALITY OF LIFE BASED ON BEST AVAILABLE EVIDENCE

a. All older patients with a positive risk screen should have a Comprehensive Interdisciplinary Geriatric Assessment for individual special complex needs.

i. Appropriate screening is undertaken to identify frail older patients at risk of adverse health outcomes e.g., falls and injuries.

ii. Following the assessment an interdisciplinary care plan is developed, implemented and monitored on a continued long term basis.

b. Rehabilitation programs are in place to prevent functional decline of older persons.

c. Services should adopt Clinical Practice Guidelines available like Infection Prevention and Control and Antibiotic Stewardship in the management of acute medical, chronic degenerative conditions, and geriatric syndromes like polypharmacy, dementia, depression and delirium, etc.

6. SAFETY AND SECURITY

Freedom from harm and injury is ensured in all healthcare settings.

a. Policies on older persons abuse/neglect are in place, strictly implemented and monitored.

b. Policies on appropriate use of physical and chemical restraints are documented and implemented.

c. Secured facilities are provided for the safekeeping of money and valuables of the older person/resident on their behalf. The provider's level of responsibility for the older person's possession is explicit and understood by the service user including their family.

d. Policies on disaster and hazard mitigation are in place in all healthcare settings. acEHCD

e. All healthcare facility workers should be appropriately credentialed and privileged.

f. All healthcare facility workers should receive training in protecting the older person's interest including those with cognitive impairment.

7. PARTICIPATION

Older persons are helped to exercise choice & control over their lives, make choices/decisions about daily aspects of life & how to spend one's time

a. Each patient's rights to consultation & participation in the organization of the residential care setting & his life within it, are reflected in all policies & practices

b. Regular family consultation or conferences are actively sought for health service delivery improvement

c. Feedback from the family and older persons or surrogate decision maker is actively sought to evaluate service delivery improvement and participation

d. Older persons and families are informed about their rights to refuse or discontinue treatment

e. The healthcare facility shall inform the older person and their surrogate decision maker as to the consequences and their responsibilities related to their decisions

f. Documentation of the participation and decisions by the older person and family are done accordingly

8. CONTINUITY AND INTEGRATION OF CARE

Person-centered, coordinated and uninterrupted health care services bringing together all elements of care tailored to the needs and preference of the older person, carer and family to avoid confusion, repetition, delay and gaps in delivery of care.

a. There is an established entry/transfer criterion to guide the institutions/provider as to the appropriate level of care for the resident/patient when the need arises.

b. Coordination and continuity of care should be evident and documented when patient is in transition from acute hospital to nursing care homes or community or back to their own homes and vice versa

c. The required document (electronic medical record-recommended) should include the patient's functional and cognitive status, plan of care, and advance care directives, current problem list, current treatment regimen including all necessary equipment needed, allergies, meals and preferences, recent labs, consultations and results.

d. Documents regarding the care provided by healthcare facility are made available to patients or surrogate decision maker. SDHTEC

e. Discharge planning should commence within 24 hours of admission in an acute care facility.

f. Comprehensive Geriatric Assessment should be updated prior to discharge in chronic care facilities and made available to accepting facilities or carer and vice versa.

g. Medication reconciliation should be provided continually.

h. Provision for home care services or a visit by a member of the multidisciplinary team when the patient is at home should be in place and properly documented.

i. Utmost effort must be exercised in order to avoid early re-admissions and frequent hospitalization.

B. ENVIRONMENTAL

Planning and design characteristics or elements needed to provide an appropriate physical environment for older people.

1. General Environmental Conditions

a. Rehabilitation Support

i. The environment enables older persons to have opportunities to participate in incidental activities, such as making a cup of tea or accessing the library, café or garden and to assume other non-patient roles.

ii. The environment is suitable for the functional and therapeutic activities taking place within.

iii. The environment provides opportunities for contextual relevant activities, such as using showers and basins similar to ones patients are likely to use at home.

iv. Provision for spaces that encourages social interaction between patients, visitors, staff and other users.

b. Adapted to the Individual

i. A protocol or policy is in place to ensure the physical environment is adapted as required to suit individual patients' needs. This protocol or policy would cover issues such as patient's personal items, restraint use, size and heights of furniture and equipment and room for gait aids and older person placement in relation to nurses' station and toilets. (refer to "Useful Tools Tips)

ii. Flexible arrangements for patients so as they would have a certain level of control over their immediate physical environment.

iii. Practice is consistent with protocol or policy as outlined above (recommendation i).

c. Night Time Audit

i. Noise in persons' rooms at night is kept to a minimum, recommended at 35-45 db.

ii. Disruption at patients' room at night is kept to a minimum.

iii. Noise levels of alarm and telephones are decreased at night.

iv. Lighting is sufficient for night toileting. HESIcT

v. Adequate night lighting is in all patient areas.

vi. Older persons have easy access to night lights.

vii. Provision for illuminated light switches to allow for easy location in the dark.

viii. Satellite/decentralized Nurse Station is recommended to allow easy access and monitoring of patients at night.

d. Level of Stimulation

i. Different functional areas are clearly demarcated by color, sign, physical layout and use of partitions to assist patients to focus on tasks.

ii. Overstimulation such as calling out and loud speaking, background noise, loud noises, crowding, disruptive behavior from other patients is avoided.

iii. Under stimulation such as repetitive spaces with little activity, large open space is avoided.

iv. Use of public address systems is minimized. If possible, have announcements made by speakers who have low-pitched voices (frequencies below 4000 Hz).

e. Level of Comfort and State of Disposition

i. The environment respects dignity and privacy.

ii. Small, comfortable and quiet areas are available for private social interaction between patients and visitors and patients and staff.

iii. Furniture is comfortable.

iv. In lounge or sitting areas, chairs are placed in small circles to encourage social interaction among patients and their families as well as staff and other users.

v. Rooms are fresh and fragrant-smelling.

vi. Rooms are kept at a temperature comfortable for the patient through use of effective cooling and heating systems.

vii. Natural elements, such as views of gardens and trees and images or photo murals of natural scenes, are provided to decrease agitation and reduce stress levels.

f. Perceptible Environmental Conditions

i. Glare is avoided.

ii. Lighting is adequate throughout (for example, 75 watts).

iii. Stairs are well-lit day and night, with light switches at top and bottom.

iv. Lighting in all areas is at a consistent level so patients are not moving from darker to lighter areas and vice versa.

v. Walls are in a contrasting color to floors.

vi. Handrails are in a contrasting color to walls. caITAC

2. Physical Environment Conditions

a. Access and Circulation

i. Provision of accessible parking spaces as required in all pertinent codes and laws.

ii. Covered walkway/canopy from the parking area/drop off, allowing easy access for wheeled equipment. There should be no steps or steep gradients.

iii. Conventional steps with contrasted edges are available.

iv. All areas are accessible with provisions of ramps for changes in elevation having a gradient of not more than 1:12 or 8%.

v. External paths are level, non-slip and free of trip hazards, overhanging branches, shrubs, leaves, weeds and moss.

vi. External and internal paths are clearly defined so as to guide the patients to their starting point without allowing them to become lost.

vii. Maintenance and monitoring of internal and external paths.

viii. Internal and external paths allow the patient to see into areas that might invite participation in an activity other than wandering.

ix. Internal and External paths, with a minimum of 2.50 meters. Width, are sufficiently clear and wide to allow two people who are each using a frame to pass.

x. There are sufficient seats and toilets along internal and external paths for regular rest.

xi. Automatic sliding doors are used in Main Entrance and Hall doorways to avoid banging of heads.

xii. All doors are wide enough, min. of 900 mm single-leaf, for easy clearance of wheelchairs, scooters and were required, beds.

xiii. Exits for patients with dementia are secure. Development of a patient alert system is recommended to notify the staff of a patient wandering out of the ward or hospital.

xiv. Full length glass panels or doors are avoided or clearly marked for visibility.

xv. Buttons in lifts are easy to reach and easily understood (for example, it is clear which the ground floor is and which is the exit floor). ICHDca

xvi. Reception is evident and accessible on arrival, and incorporates a high-low design to accommodate wheelchair users.

xvii. Waiting rooms are private and comfortable with access to food, drinks, toilets and a public telephone (including a phone link to request a taxi).

xviii. Reception and waiting rooms, as well as consulting rooms and treatment areas are in close proximity of each other.

xix. Handrails in corridors, paths, on all steps and in lifts are in accordance with AS 1428.1, Design for Access and Mobility.

xx. Windows are restricted by providing steel grilles and in the extent to which they open so that patients cannot climb out.

xxi. Areas where patients are not to enter (for example, cleaner's cupboards, and storerooms) are kept locked or camouflaged (for example, painted the same color as the wall, has a hidden door handle).

b. Orientation

i. Staff can be identified and distinguished from patients and families.

ii. There are views to outdoors and landmarks to assist orientation.

iii. Provision for visual anchors to help patients and visitors to easily locate their position within the facility. These anchors are characterized by elements that stand out and can be easily seen along the circulation paths.

iv. Large clocks and calendars are displayed.

c. Signage

i. Signage is adequate. This includes having signs at eye level and on the floor and using primary colors on all key areas that patients are required to go to.

ii. Signs using icons or symbols are familiar to older people, are easy to discern, have little detail and clearly represent their meaning.

iii. Directional signs are efficiently and adequately placed so as to enable patients of independent way-finding.

iv. Text is easy to read and there is not too much information on one sign.

d. Surface Treatments

i. Flooring is free of clutter and hazards, such as cords and loose rugs.

ii. Flooring is in good condition, firmly attached and appropriate for tasks undertaken.

iii. Floor surfaces are non-slip.

iv. There is an absence of raised edges on the floor/ground. Joining strips between different floor surfaces are as smooth as possible so as not to create resistance when wheeled equipment is being used.

v. Changes in floor surface are clearly defined.

vi. Appropriate floor cleaning equipment is available for the types of floor coverings.

vii. Floor cleaning procedures are developed and take into account safety of patients and staff.

e. Equipment and Furniture

i. Furniture is secure enough to support a patient should they overbalance.

ii. Arms on chairs and commodes are secured and sturdy. TCAScE

iii. Unused furniture is stored in a separate area when not in use. Adequate storage space is provided for equipment, mobility aids and furniture so that it is easy to access when required.

iv. Properly positioned so they do not have the potential to strike other objects when in the open position.

v. Chair legs stand straight, rather than sticking out on angles and posing a tripping hazard.

vi. Chairs have non-slip, easily cleaned fabric.

vii. Devices such as telephones, speakers and warning sounds can be adjusted to the needs of the individual.

viii. Equipment and mobility aids, which promote patient independence and patient and staff safety (for example, wheelchairs, footrests, pressure cushions, mobility aids, electric beds, slide sheets), are available when needed.

ix. All features on wheelchairs work effectively, including footrests being easy to move, wheels and brakes being in good working condition with good tread on tires, and wheels are moving freely. The type of wheel/tire must be appropriate for the floor surface to maintain push/pull forces for staff to within acceptable limits and to facilitate independence for wheelchair users.

x. Gait aids have rubber stoppers in place and are in good condition, and wheels and brakes are in good working condition with good tread on tires and wheels moving freely.

xi. There is a proactive maintenance program in place for equipment.

3. Space-based Conditions

a. Toilet and Bathroom

i. Patients can see toilet facilities from areas they frequently occupy.

ii. There is a sufficient number of toilets close to activity areas so patients do not have to travel too far.

iii. Toilet flush and sink taps are accessible and user-friendly (for example, automatic or lever handles).

iv. Receptacles for soap are designed so as not to create a striking hazard (for example, where practicable they are recessed into the wall).

v. There is adequate space in the bathroom for patient, staff member and all patient-handling equipment used. cTDaEH

vi. Hand basins in bathrooms allow wheelchair access- doors should have a min. width of 900mm.

vii. Walls around shower/bath and sink are marked in contrasting colors to the shower/bath and sink.

viii. Toilet paper dispensers are accessible.

ix. Grab rails in bathrooms are adequate to match patient and staff needs.

x. Chair and commode heights are adjustable so that patients can rise and sit with ease. Toilet heights are raised using over-toilet frames as required.

xi. Water temperature of taps is limited so that it cannot scald.

xii. Doors into bathrooms and toilets open outwards so an older person cannot fall against the door and block access.

b. Bed-based Bathroom

i. Shower bases are step-less. The gradient of the bathroom floor must be assessed to ensure: n

ii. Adequate drainage after the shower is used (otherwise, it's a slip hazard)

iii. The floor gradient of the shower base is located far enough away from the toilet to avoid wheelchairs rolling away from the toilet down the slope.

iv. Receptacles for soap, shampoo and washers are easy to reach, including when seated, and do not require bending over to reach them.

v. Taps in showers are easily accessible for patients and staff (on side rather than back wall). Commodes and shower trolleys have rubber stoppers in place and are in good condition, and wheels and brakes are in good working condition with good tread on tires and wheels moving freely.

vi. Clothing hooks and towel rails are easily accessible from the seated position. In addition to this, IV hooks must be provided in place of IV stands and trolleys while inside the toilet and bath.

vii. Provision of grab bars for assisted use of all fixtures.

viii. If possible, a glass sliding door to the shower area shall be used to separate the water closet and lavatory to keep the area dry and prevent patients from slipping.

c. Bedroom

i. Wash basin must be provided at the entrance of bedrooms for carer's hand washing before attending to the patient.

ii. Firm mattresses are used to provide support when moving in bed.

iii. Bed height is adjustable but kept at lowest height for patient safety. Beds are able to be adjusted to an appropriate height for the carer to undertake patient handling and patient care tasks without bending. Electric beds are recommended.

iv. Color of the bed and sheets is in contrasting color with the floor.

v. Bed wheels and brakes are in good working condition with good tread on tires and wheels moving freely.

vi. There is access to a bedside table positioned so that placing items on it does not require undue stretching and twisting.

vii. A gender mix is avoided in patient rooms.

viii. Patients are encouraged to bring personal belongings to promote recognition of their room and increase comfort. Personal belongings are assessed for suitability in the health facility so that they do not create hazards for patients or staff. cSaATC

ix. Patients' rooms are numbered and personal memorabilia is used for assisting patients to find their room.

x. Where a television is provided, the appropriate design and placement of it in the patient's room enhances the older person's comfort. This includes positioning for easy viewing and listening, and easy-to-use controls.

xi. Patients have a choice of whether to eat in communal dining areas or in their bedroom.

xii. Ceilings are designed to support ceiling hoists.

xiii. The environment is made accessible for visitors.

xiv. Call bells work.

xv. Call bell positioning is flexible, allowing for right and left hand use by patients, and the buttons are easy to push. They should also be within easy reach when the patient is lying in bed or in the toilet or shower. Turn-off buttons for staff are easily accessible.

xvi. Light switches are within easy reach and accessible to patient (no higher than patient's shoulder height).

xvii. A patient reading light is mounted at each bed head.

VII. ROLES AND RESPONSIBILITIES

A. The Health Facilities and Services Regulatory Bureau — shall ensure that licensed healthcare facilities are compliant to the standards of care for older persons.

B. The Health Facility Development Bureau —shall coordinate/collaborate with the different concerned bureaus of the DOH-CO in the provision of technical assistance, capability building, consulting and advisory services in the implementation of the principles of the standards of care for older persons in healthcare facilities.

C. The Health Human Resources Development Bureau —shall in coordination with National Center for Geriatric Health (NCGH) incorporate in the development of human resource for health the principles of standards of care for older persons.

D. The Disease Prevention and Control Bureau-Degenerative Disease Office — shall in the development of plans, programs policies, projects and strategies for disease prevention and control, provision of coordination, technical assistance, capability building, consulting and advisory services follow the principles of standards of care for older persons in this guideline.

E. The National Center for Geriatrics Health under JRRMMC — shall incorporate the standards of care for older persons in its mandate to provide gerontological education, training and specialization of the medical and allied professionals, community capability training, research and program development. cHDAIS

F. The PhilHealth — shall ensure the principles of standards of care of older persons in accrediting licensed healthcare facilities are observed and followed.

G. The Health Promotion and Communications Service — shall in consultation with HFDB and DPCB develop and implement national communication plans/campaigns to promote the standards of care of older persons.

H. The DOH-Regional Offices — shall oversee the implementation of policies and programs and enforcement of regulatory policies at the regional level of this guideline.

I. The DOH Hospitals, LGUs and other concerned Healthcare Facilities — shall ensure that the standards of care for older persons in this guideline are complied with.

VIII. EFFECTIVITY

This Order shall take effect immediately.

(SGD.) PAULYN JEAN B. ROSELL-UBIAL, MD, MPH, CESO IISecretary of Health

n Note from the Publisher: Copied verbatim from the official copy.