Reference No.

Measurable Elements Checkpoints Compliance Assessment Method Means of Verification

Area of Concern - Inputs
Standard C3 Facility has a defined and established procedure for effective utilization, evaluation and augmentation of competence and performance of staff

(1) 8 days induction training, 20 days training of

module 6& 7, 5 days NCD module. (2)
Supplementary & refresher training for 15
days/year. (if applicable) (3) ASHA facilitatory is
trained for Basic physiotherapy ( where ever
The staff is provided training as per defined core elderly & palliative care packages are
ME C3.2 competencies and training plan AHSA is trained as per mandate 2 RR/SI available),Training on Eat right toolkit
Area of Concern - Support Services
Standard D5 The facility ensures health promotion and disease prevention activities through community mobilization

The Ayushman Arogya Mandir facilitate planning

& implementation of health promotion and
disease prevention activities through There is a system of taking feedback from by MO, Ask the example where actions are
ME D5.1 community level interventions ASHAs / VHNSCs/ VHND to improve the services 2 RR/SI taken based on feedback
(1) Based on Population enumeration, village
health register, CBAC, ASHA diary, VHSNC
Check the process followed to identify key records, RCH registers etc (2) Based on social
challenges and list of priorities for monthly resource map - it identify location & vulnerable
campaigns 1 RR/SI section
Area of Concern - Wellness & Clinical Services
Standard E9 The facility has defined & established procedure for screening & basic management of Mental Health ailments as per Operational/ clinical guidelines

(1) Check Community informant decision tool

(CIDT) is used for identification by
ASHA/MPW/CHW (2) Standard screening tools
are used by CHO viz :Screening tool for
dementia, Screening tools for Epilepsy, patient
health Questionnaire (PHQ-9) for depression ,
suicide risk assessment & Alcohol use disorder
identification test (AUDIT) for alcohol disorders.
The facility provides services under mental Check Staff uses specific tools for early Check staff is trained to use these tools. (3)
ME E9.1 health Program as per guidelines identification & screening of MNS 0 RR/SI Check number cases screened & identified
Standard E10 The facility has defined & established procedures for management of communicable diseases as per operational/ clinical guidelines
Check register is maintained & updated,
The facility provides services under National reporting in form M 1 (ASHA/SC), M2 (if using
vector Borne disease control programme as per slides), M4- fortnight complied report of malaria
ME E10.1 guidelines as per guidelines NVBDCP register & records are maintained 2 RR/SI surveillance submitted by SC
Standard E11 The facility has defined & established procedures for management of non-communicable diseases as per operational/ clinical guidelines
Through trainer Yoga instructor (ASHA/ Asha
The facility promotes services for health & Check Ayushman Arogya Mandir is providing facilitator/ Yoga teacher/ physical instructor
ME E11.5 wellness Yoga services 2 RR/SI from school)
Major Gaps (Any)
Evidence (Any)
Strength (Any)