Sukh Sagar Medical College & Hospital Owned by: Gyanjeet Sewa Mission Trust, Jabalpur. Last Assessment Date 17th March 2016 Sr. Deficiencies No. reported from MCI 1 Although Bed Occupancy is 60.66% on the day of Assessment more than 6070% patients were fake.

COMPLIANCE Bed Occupancy on the day of assessment was 84%. Assessor Dr Patel only counted the patients which were on bed, but the patients who went to radiology department for investigations were not counted, also 16 operations were done on the day of assessment those patients were also not counted. Even 60.66% is also as per the regulations. Hence, NO Deficiency. Remarks about the genuineness of the patients are based on the summery which does not bear dean’s signature and was created on the back of the dean, and later on added to the report, because when report was sealed in the dean’s chamber this concocted summery was not put inside the envelope, this is the violation of the Assessors Guide, hence needs to be ignored. However, without prejudice to our rights and in addition to the above our submission is as below: As per the Standard Assessment Form (SAF) of Compliance Verification Assessment dated 17th march 2016, there were total of 182 Patients in General Wards, 16 Patients in ICUs, 8 Patients in Casualty and a total no. of 16 Operations that were performed on the day of Assessment dated 17th March 2016 which were verified and noted by the Assessors in the SAF. The observations regarding "Fake/Not Genuine" patients was not made part of this SAF Report nor Signature of the Dean was obtained on any documents pertaining to it. It is specifically mentioned in the Assessor's Guide 2016-17, (Annexure-1, relevant portions highlighted) that no document other than the main SAF Report is to be made part of Assessment Report, therefore; remarks/observations cited are ought to be ignored, as the same was neither brought to the notice of the Dean or MS nor the signatures of Dean or MS were obtained on any such documents related to the remarks as claimed in the Executive Committee meeting of MCI dated 13th May 2016. Annexure No.1 The SAF Report was signed and sealed by all the assessors in the presence of Dean and it did not contain any additional documents then. The observations cited in the Executive Committee meeting came as surprise to us as these remarks were not the part of SAF Report. The mentioned remarks must have been submitted later and/or on someone's persuasion, and

are twisted facts. However, the observation regarding "Fake/Not Genuine" patients is made only for 6-7 Patients and we don’t understand how it is concluded that 60% to 70% patients were "Fake/Not Genuine". It seems that the intention of assessor Dr. Mahesh Patel is to harm the institute, otherwise, why were the observations not brought to the notice of the dean and clarity was sought. It was done with clear intention of mala-fide. These deceitful and twisted observations are made by assessor Dr. Mahesh Patel and were purposely not brought in notice of the Dean as the same would have been clarified then and there itself. The process of Assessment is to be carried out by the assessors and the Dean of the Institute as mentioned in the Assessor Guide. Concealing deceitful observations obtained by trickery and threatening Junior Doctors and Nursing Staff, and then making them part of SAF Report, that too after the main SAF Report was signed and sealed by the Assessors clearly proves the malafide of Assessor Dr. Mahesh Patel. It is also important to note that there are no such negative observations made by the Assessor Dr. Sankardas Chattopadhyay who is a Surgeon and Clinical Specialist but, Dr. Mahesh Patel who is Faculty of Pathology questioned the genuinity of Patients who were advised admission by Professors and HOD's of Clinical Departments. Annexure No.2 The requirement of having 60% Bed Occupancy as mentioned in the MSR is fulfilled by the institute as per Standard Assessment Form report. The observation "Not Genuine/Fake" is wrongly stated as there was not even a single patient whose details like name, age, current address was false or fake. The Dean who is Distinguished Faculty Member and is an Ex-Dean of Government Medical College for 5 Years also understands the importance of clinical material needed for a teaching institute. Also, to bring to your notice, that the posting of students in the Hospital for teaching purposes will only happen from the 2nd Year as per Graduate Medical Regulations. Annexure No.3 Had it been true that the patients (if) does not merit admission, then observations related to the same should have been made part of the SAF Report and signatures of the Dean be sought on the SAF Report itself, and such patients should have been excluded from the head count and then the bed occupancy %age should have been derived, as it is done in the assessments of other institutes as a standard practice by MCI, but in our case the same was concealed and produced later on. The purpose of Assessment and

the duty of Assessors is to facilitate the process for obtaining permission from the concerned authority and not to produce concealed deceitful observations to misguide the concerned authorities with the intention to damage the Institute. The fact is that there were a total of 248 Patients in General Wards on the day of assessment dated 17th March 2016. If permitted, case sheets of each and every patient can be brought on record. The admission to these patients were advised by Distinguished Post-Graduate Doctors with years of Clinical & Teaching Experience. The genuinity of patients requiring admissions cannot be doubted as the Individual Doctor deemed it necessary to advice admission to those patients. It is important to note that Dr. Mahesh Patel did head count of Patients in all wards and got the signatures of Nursing Staff on the Note Sheet written by him, the nursing staff as can be seen in video, did not even read and signed the sheet and it seems are oblivious to the remarks written in the note sheet. It is clearly seen in the video that he entered the ward and counted the patients and then entered in the Note Sheet and got it signed by Nursing Staff. However, no consideration for counting patients was given to the 16 Patients who were in OTs as they were not on their bed and their file was not available, because the same goes with patient to the respective OT. Also, it can be noted that as per the Report there were total of 102 X-Rays and 23 USG that happened on the day of Assessment till 2:00 PM and number of IPD patients were in the queue to get their X-rays and USGs done who were again not counted owing to the same reason, that they were not on their bed. We cannot halt the functioning of the Hospital and make all the patients stick to their beds just because Inspection is going on. It was the abusive language of assessor and threat to JR's that their registration will be cancelled that created a terror and they were pressurized and made to sign on the vague statements which are lately brought on record. Also, during the round of wards, all the HOD's, Professors, Associate Professors, Assistant Professors and even Senior Residents were not allowed to enter the ward during the round and neither the HOD or any Consultant were given chance to explain about any patient and neither was their counter signature taken on any statement by Junior Resident. It was a surprise to the MS and Dean when one of the assessor said that the Patient count that they will consider is 182, to which they did not contest as it was above the required number of 180. There is also no remark in the SAF report in the column where it is recorded that the bed occupancy is 84% i.e. 248 Numbers. If the same was not true, the assessors could have mentioned there that

the data was inflated as they have been doing in the assessment of every other institute. Also, as mentioned in the Assessor Guide under Section Infrastructure point 4, that: “Any discrepancy that is observed between statements made in Form A, B & Clinical material supplied by the institute and the actual position as observed during assessment, should be clearly marked and brought to the attention of the Dean/Principal of the institute and her/his signature should be obtained at the relevant place.”

Not abiding by the process proves that there is some hidden agenda by Dr. Mahesh Patel. Please see point wise explanation on the remarks cited:

A. Observations: In medical male ward three patients named (1) Mr. Channu Thakur M-45, IPD No. 302567 (2) Mr. Sukhram Thakur M-42, IPD No. 302570 and (3) Mr. Sunny Thakur M-25, IPD No. 302563 were shown as admitted. During round, on detailed enquiry, JR of Medicine Dr Suhani Dubey has confessed and given written statement that these patients are not actually admitted. These three patients are fake admissions. Explanation: Please see below Affidavit by Dr. Suhani Dubey, stating the incidence that happened on the day of Assessment. It is self-explanatory and shows how the so called statement was obtained from her. Annexure No.4 B. Observations: In female medicine ward patient named Mrs Seema Dhurve, F-40 yrs, IPD no. 2511, OPD No. 150009 was fake patient. Patient said she was admitted 15 days before but resident doctor preeti yadav has said and as per case sheet also she was admitted on 15/3/2016 before 2 day, no medicine, no attendants was there, she was admitted for anaemia but no blood report was available till 17th march, patient said she is residing in Rajasthan while in case sheet address was Jabalpur. Explanation: There is no evidence proving that this patient was fake, Assessor did not consult the admitting doctor for verification. Regarding the residing observation, she could be a native of Rajasthan and may be temporarily residing in Jabalpur, it is not conclusive enough to say patient was fake. On detailed enquiry it was revealed that the Assessor Dr Mahesh Patel took the original case sheet of the patient.

C. Observation: In Gynae ward patient named Mrs. Shanti Dhurve f 30 yrs IPD no. 302582, OPD No. 3170015 was fake. When inquired patient said she was admitted one week before, while staff nurse statement and case paper record shows that she is admitted on the day of assessment. Explanation: The original case sheet of this patient was taken by assessor Dr. Mahesh Patel, she was admitted on the day of assessment but no-where in the observations it is mentioned that the patient was not suffering from any ailments and hence cannot be termed as fake. D. Observations: In male Surgery Ward, Patient named Mr. Laxman Patel, M-24 Years, OPD Number. 030008, IPD No. 2086 was not genuine. He was admitted before 13 days with only complaint of Gastritis. Explanation: Patient Mr. Laxman Patel is admitted under Dr G.K.Pathak who is not only Assistant Professor but also DMS of Hospital, he admitted patient under Conservative Treatment as mentioned in his file also and patient was under Injectable till 12th March and had undergone various Clinical Examinations and Diagnostic Tests. He then underwent Endoscopy on 18th March and was discharged on 19th March. Annexure No.5 E. Observations: In surgery female ward Dr. Kunal Rupre, JR in Surgery Department has confessed that Patient named Mrs Dassobai was admitted before 2 days but no treatment was advised/given. Explanation: Patient Dassobai aged 65 Years was admitted with complaint of pain and distress in Epigastrium, she underwent clinical examinations and Investigations and underwent endoscopy on 18-03-2016 with no abnormalities and was discharged on 18-03-2016. Only empirical treatment was given till endoscopy was done and cause detected. Annexure No.6 F. Observations: In Gynae ward Patient named Kallobai IPD No. 302575 was fake patient. Patient said she was admitted 5 days before but as per the Nurse Statement and case record, she was admitted one day before. Explanation: Patient Kallobai was admitted with complaint of Post-Menopausal Bleeding on 16th March. She was an old patient with recurrent Post-Menopausal Bleeding who often visited the OPD but on 16th was admitted for

Observation & Work-up, treatment was started, lab investigations and USG was advised on 16th itself. Due to Endometrial Thickening as observed in USG, patient underwent Therapeutic Curettage and was then discharged on 19th. Annexure No.7 2

It appears that most of the residents had come for inspection only

Remarks are based on the summery which does not bear dean’s signature and was created on the back of the dean, and later on added to the report, because when report was sealed in the dean’s chamber this concocted summery was not put inside the envelope, this is the violation of the Assessors Guide, hence need to be ignored. However, without prejudice to our rights and in addition to the above our submission is as below: Again, Assessor Dr. Mahesh B Patel has noted the same without any logical reasoning as to how he concluded the same. Whenever there are such findings, the same are noted on SAF itself, and residents found not to be staying in the campus are specifically mentioned in the SAF report and not considered in count of total Faculty / Resident, whereas in our case no such remarks or noting are made on the SAF, All the residents were present and were verified by the assessors during documents verification process, and only after they were approved, they were entered in the list of residents on SAF, that is why no deficiency of Faculty or Residents is mentioned in the report. During inspection Dr. Mahesh B Patel himself has verified each and every room of the hostels and other residential quarters, all of this is an afterthought to deprive us from getting permission, otherwise these residents should have not been counted in the faculty and deficiency chart in the SAF. As specifically mentioned in the Assessor Guide 2016-2017, (Annexure-1, relevant portions highlighted), No document other than the Standard Assessment Form is to be made part of Assessment Report, therefore; remarks cited cannot be considered, as the same was neither brought to notice of Dean and neither is there is any document related to this deficiency that bears Signature of the Dean. Each and every Faculty and Resident was verified by the Assessors during the process of Declaration Form Verification and Hostels were inspected for Occupancy by the assessors during Hostel Inspections on day of Assessment between 12:00 Noon and 3:00PM, also captured in the video. The Assessment Report when signed and sealed by all the assessors & Dean did not contain any information pertaining to this remark/deficiency. These basis of these deceitful observations obtained by threatening the JR’s was an afterthought, that he entered the Hostels once again with the other two assessor after the Assessment Report was signed and sealed at 7:00 PM and after the working hours of College at 8:30 PM which is not permitted as per the Assessor Guide 2016-2017 under section general instructions, and threatened the Junior Residents

and terrorized them to get concocted and vague statement from them. It is to be noted that the other two Assessors did not take any such statement and neither did harass any Junior Doctor. The faculty and residents as verified by the Assessors was total 116 as stated in the Standard Assessment Form. For each one of them, the original verified declaration form was collected, signed by the assessor and was submitted to the MCI along with attendance sheet and Standard Assessment Report. These faculty and residents signed the attendance sheet within 1 Hour of arrival of Assessor as mandated by the Assessor Guide. Each and every faculty and resident is then verified individually with checking of their documents including Degrees, Registration, Declaration Form, Allotment Letter, Address Proof, Photo id and are cross checked for correctness. It is only after the assessors are satisfied that the faculty and residents are working in the institute that they sign the Declaration form for each and every faculty and Resident. It was after this exhaustive process that the Assessors and the Dean then signed the Standard Assessment form. Frustrated by seeing the report and finding things in order, the assessor Dr. Mahesh Patel while leaving the Institute at 7:45 PM again went to the Hostels and checked each and every room personally to see whether Residents are in room or not. A total of 35 Residents are staying in that Building of which only 2 might not have been available at that time there as they could be anywhere in the campus or even outside the campus as it was not their Duty hours. The other two assessors also checked the designated rooms and found no anomalies but it was only Dr. Mahesh Patel who threatened the JR’s and could get vague statements of them that too of only 3 of them. Not all the JR's feared him and gave statements. It is important to note out here that if any such rejection of Faculty or Resident is done, the same is incorporated in the Standard Assessment Form as was done in our previous assessment and is a standard practice which can be seen in any Assessment Report, where in basis for rejection of faculty is specifically mentioned in the Standard Assessment Form bearing the Signature of Dean and the Assessors. The mala fide can be very clearly seen here as it was not in the notice of the Dean that such a thing is done. Also, the assessors are supposed to complete the process of Inspection within 9:00 AM to 6:00 PM as per Assessors Guide 2016-2017, under section general Instructions. These statements were recorded after the working hours of college without information to Dean and after Sealing of Report was done. The total faculty and Residents required is 111 as per MSR and total available in all departments is 116 as recorded by the Assessors. Vague statements fiercely & forcefully were obtained from few Junior Residents by threatening them, who are 24-26 Years of age and are facing MCI Inspection for the first time. Statements extracted from them under pressure does

not jeopardize the availability of 65 Faculty Members and 46 Residents who were verified by the Assessors themselves and considered for calculating deficiency. Please see explanation below for the statements obtained by the Junior Residents: A. Observations: One doctor Ashish Patel JR in surgery Department joined the department before 8 Months nut he does not know name of other Residents in the Surgery Department. He also does not know number of Residents in his department. Explanation: Dr. Ashish Patel joined the institute 8 Months back as Tutor in the Department of Forensic Medicine on 2208-2015 vide Appointment Letter GSMT/SSMCH/Apptt/Faculty/Resi/2015-16/283 and was transferred to Department of Surgery on 25-02-2016 vide office Order ref. no. SSMCH/2016-17/528. It is wrongly stated that he was in the department since 8 Months, these same documents were enclosed with the Declaration of Dr. Ashish Patel and he was counted as a Junior Resident as per the Standard Assessment Report also. Annexure No.8 He could not have answered everything due pressure as desired by the Assessor Dr. Mahesh Patel, but that does not mean that he came only for Inspection. Also, to be noted he was available for previous Inspection as well that happened on 7th January 2016 and these are surprise inspections and attendance sheet is signed within 1 Hour of arrival of Assessors. B. Observations: Dr. Sravya, working as JR in Obs/Gynae Ward has given written statement that she does not know handwriting in case papers of patients admitted in Obst/Gynae Ward. Explanation: Dr. Sravya joined the institute as Junior Resident in the Department of Forensic Medicine on 22/1/2016 vide Appointment Letter GSMT/SSMCH/Apptt/Faculty/Resi/2015-16/446 and was working in Department since then. These same documents were enclosed with the Declaration of Dr. Sravya and she was counted as a Junior Resident as per the Standard Assessment Report also. It is possible that she does not know the hand writing in Case sheet as Doctors comments in Case Sheets are filled in by Senior Resident and Assistant Professor for Obs/Gyane Department. If permitted, sample case sheets can be brought which will show that most case sheets were made by SR & Assistant Professor of the Department.

C. Observations: Dr. Mercy, JR in OBGY Department has given written statement that she did not write any case sheets of any patients in OBGY Ward. Explanation: Dr. Mercy is in the OBGY Department as is posted in the OPD duty since 1-03-2016. It is absolutely possible that she has not written case sheets because she was not posted in the Ward and was working in OPD. Also, as explained previously, the JR’s are not permitted to write case sheets owing to less experience and Senior Resident and Assistant Professors ensure to write all Case Sheets themselves. D. Observations: In Department of surgery, SR in general Surgery Dr. Neelkamal Suhang has given written statement that she does not know details of patients admitted in surgery ward and he does not know also who has written all case papers of patients in Surgery ward. Explanation: Dr. Neelkamal Suhane joined the institute on 8/7/2015 date vide letter number GSMT/SSMCH/Appt./Faculty/Resi./2015-16/282, He was counted as Senior Resident in previous inspection dated 78/1/2016 also, Attached herewith is the statement of Dr Neel kamal Suhane stating that he has not given any written statements in “which he has admitted that he doesn't know the whereabouts of the patients”. Hence, the allegations are false, twisted facts and baseless. Annexure No.10 E. Observations: Dr. Vipin Singh, JR in surgery department room no. 5 in resident Hostel has given written statement that his room partner Dr. Akhilesh Shroti SR, is not staying in Hostel Campus. Explanation: Assessor Dr Mahesh Patel went to the residents hostels after completing the assessment process at around 8:00 PM, he entered all the rooms to check weather residents are staying or not, he used abusive language with them and threatened them and got such statements from residents which cannot be relied upon. Attached herewith is the statement of DMS of the institute Dr. G K Pathak who has witnessed all this. Annexure No.11 F. Observations: Dr. Om Prakash Vishwakarma, JR in Skin department has given written statement that he is staying in Room No. 12 alone. In his room, nobody is staying, while Dr. M Narhari, JR in Medicine has given written statement that he is staying in Room Number 12.

Explanation: Attached herewith is the statement of Dr. Om Prakash Vishwakarma, which is self explanatory. DOJ of Dr M Narahari is 14/3/2016, he was allotted Room No. 12 and was sharing room with Dr. Om Prakash Vishwakarma, but somehow he couldn't admit the same before assessor because of his attitude. Annexure No.12 3

Dr Sandeep Reddy, Junior Resident in the department of ENT has appeared at MCI inspection for three times in same academic year

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Casualty: Out of total 8 Patients in Casualty 3 had

The observation that Dr Sandeep Reddy has appeared for Inspection in some other institute was brought to Notice of the Dean for the first time at 5:00 PM on 17/3/2016 during the assessment process. As soon as same was brought to notice we submitted his Joining Report, Appointment Letter, Mandatory Declaration to the assessors. This a standard practice of the institute to get declaration form of Junior Residents at the time of joining specifically for the reason that they don't cheat us and give us false information as there is no mechanism available with us to check whether a Candidate has appeared for MCI Inspection from some other institute before or not, as we do not have access to Latest MCI database of Faculty & Residents. The faculty and resident’s information for candidates are uploaded after 3 Month to 4 Month on the website after the inspection of any Institute. Our inspection was held on 17-03-2016 and till date there is no information of our faculty uploaded on the website, this makes it impossible for us to check if a candidate has appeared for MCI Inspection or not and we have to base everything on the information given by the candidate whether he/she has appeared for MCI Inspection from some other institute in the same academic year. The dean or the Institute was not aware of Dr Sandeep Reddy's appearance in MCI Inspection in some other institute before the day of assessment i.e. on 17/3/2016 It is important to note here that Dr Sandeep Reddy joined the institute on 19/12/2015 date and has been working in the department of ENT and he was also available in the previous inspection held on 7th January 2016 and was counted as a Junior Resident as per SAF Report prepared by the then Assessors. The fact that he had appeared in some other institute before inspection was not brought in notice in the inspection held on 7th Jan 2016 neither any communication regarding same was received to Dean from MCI when Compliance report was sent which had name of Dr Sandeep Reddy as Junior Resident in the Department of ENT. We had total of 8 Junior Residents in the Department of Medicine against the requirement of 6, the same is documented in the SAF report for Inspection on 17-3-2016 as well by all the three assessors countersigned by Dean. It was specifically asked to the Assessors that if needed we can issue transfer letter to one of the Junior Resident from Medicine Department to department of ENT, but were not persuaded by the Assessors and they considered Dr Sandeep Reddy as Junior Resident and did not count him as invalid and marked no deficiency of Resident in the Department of ENT. Annexure No.13 It is important to note that in requirement of Infrastructure as per MSR for LOP Inspections in Emergency Ward only 10 Nos beds are required, and we have provided total of 25 general ward Beds, 4 Beds for Emergency ICU and a Major OT and a minor OT as per SAF Report prepared by the Assessors themselves on 7-01-2016.

only Lower Backache and did not warrant Admissions.

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Total of 8 beds were occupied on the Day of Assessment and there is no such requirement of Bed Occupancy for Emergency Department in the MSR, Regulations or anywhere. Regarding the three patients which are objected to having “low backache only” the explanation is as below: The Emergency Wards are used for Admission to Patients only after 4:00 PM and all patients who come to Hospital after 4:00 PM are attended by Casualty Medical Officer deputed in the Emergency Department who depending on patient complaint and primary examination starts the treatment. If the patient is admitted required admission as per the Casualty Medical Office then, he/she is admitted in the Emergency Department and the next morning is seen by the Respective Department Consultant to give further treatment or shifted to Respective Department Ward or Discharged after necessary Examination / Review of Diagnostic Test Result conducted in evening previous day. Patients come to Hospital from far off places after 4:00 PM using public transport in case of Emergency or any Medical Complaints and prefer being in Observation in Emergency Ward till the time Senior Consultant examines the patient in case of Non-Emergency Cases in which the On Call consultant attends the patient immediately. Challenging the treatment advised by Casualty Medical Officer who is a qualified Doctor in Emergency Department is absolutely unjust. As per our Hospital Philosophy and Culture and same is discussed in closed room between MS, Dean and concerned Doctor. We do not appreciate the Assessors observation that the patients did not merit Casualty Admission implying incompetency of the Casualty Medical Officer. Hence NO DEFICEINCY There were nil There were nil Caesarean Sections and 2 Normal Deliveries on the Day of Assessment as noted in the SAF Report prepared Caesarean by Assessor and Signed by Dean. The explanation for same is that we cannot hunt on for Patients who are pregnant and Sections on the requiring Caesarean Section. Whosoever patients come to Hospital for either Normal Delivery or Caesarean Section are Day of given treatment as we have a Department of OBS/Gynae with 4 Consultants and 2 Senior Residents all competent to perform Assessment Caesarean Section and Normal Delivery. The department is headed by the Dean of the who is a remarkable and known Gynaecologist. Also, there is no specific that how many Caesarean section should happen on each day or on the day of Assessment in the MSR. Hence No Deficiency Histopathological There is no requirement as such for number of Investigations performed on each day in the MSR. Workload was As per Dr Mahesh B Patel there were total of 2 Histopathology, 1 cytopathology, 12 microbiology, 26 serology only 2 and investigations that happened on the day of Assessment, however it is important to note that these are the data's taken by Cytopathology the assessor at 1:00PM whereas the department functions till 5:00 PM. In total there were a total of 2 Histopathology, 1 Workload was 1 cytopathology, 12 microbiology, 26 serology, 191 Biochemistry, 609 Haematology investigations that were performed on on the day of the day of Assessment which is also noted in the SAF Report. Hence No Deficiency Assessment

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which is in adequate Male Nursing Staff was Posted in Female Ward. 60% Nursing Staff is Male and Most of whom are untrained. One Male staff Mr Pankaj Patel is In charge of 4 Wards.

Student Hostels: There is no Visitor room, Warden room, Mess etc…

No Such requirement in MSR, hence No DEFICIENCY, However, It is surprising to note that the Deficiency against which the observation regarding Male Nurse is noted bears no relation with the deficiency that was supposed to be addressed. Deficiency: Item Number 12. There was no woman in Labor Room. Compliance Submitted by Institute: There was no patient at the time of inspection but 1 patient Named Preeti was admitted late in labor at 1.54 PM delivered at 2.28 PM on the same day. Photocopy of birth Certificate Attached. Remarks by Assessor after Assessment: More than 60 percent nursing staff are male, and they are posted in female wards also. The above reproduction is self explanatory. However, the total beds in Hospital is 300 out of which Male Beds are approx. 60% and rest are Female Beds and Paediatric Beds. So, having 60% staff as male nurse is absolutely valid, and we cannot discriminate appointment to a post on basis of his sex. The parameter to judge is competency and not sex. Regarding remark of untrained nurses, the entire nursing staff is professionally qualified with BSC or GNM Degree with Internship. They assessor has purposely tried to mislead by saying in his foolish remark that one Nursing Staff is in charge of 4 Wards, but did not mention that these wards have total of only total of 24 Beds in the same ward block, this ward has 4 Male Beds in Ophthalmology, ENT and TB Chest each and 4 Female Beds in Ophthalmology, ENT and TB Chest each which is recorded by the Assessors in the Report of 7th Jan 2016. We absolutely have only one in charge for these 24 Beds with Additional Nursing Staff for each Department as per requirement, in-fact each ward is of capacity 30 and we have 1 In charge for each Ward and Additional Nursing staff in the wards are deputed as per need and requirement. Again, it is surprising to note that the Deficiency against which the observation regarding Visitor Room etc. is noted bears no relation with the deficiency that was supposed to be addressed. Deficiency: Item Number 17. Students' Hostels: Accommodation available is 112 against requirement of 113. Only Beds are provided; no other item of furniture is available in girls' hostel, Visitor Room, Recreation Room and Computer room is available only in ladies Hostel & not in Boys hostels. Compliance Submitted by the Institute: In student’s hostel 114 accommodations is available & they are already furnished with beds, chair, table & almirahs.

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Remarks in SAF Report after the Inspection: In student hostel, in boy’s hostel there are 32 rooms × 2 occupancy = 64 capacity and in girls hostel 25 rooms × 2 occupancy = 50 capacity were shown at the time of inspection. In these both hostels, no mess facility available, no warden room, no visitor room, no study room. In some rooms minor civil work is pending, most of room’s bathroom’s door fitting is incomplete. No railing available in staircase in all hostel buildings. It can be noted here that Deficiency was pertaining to number of rooms available stands rectified as per their own statement in the report. However, please see reproduced part of Assessment Report for Inspection done on 7th Jan which states "Visitor Room, Recreation Room and Computer room is available only in ladies Hostel, and not available in boys hostel”. We have video and pictures of Dr Mahesh Patel inspecting Recreation Room, Visitor Room, Mess and Computer Room of Boys Hostel, which can be made available. Hence, No Deficiency Resident Hostel: There is no requirement of Facilities like Visitor Room, Recreation Room and Computer Room for Resident Hostels as Many Residents Mentioned in MSR under point B.10.1 and requirement of these facilities is only for Boys Students Hostel and Girls Students are not staying in Hostel mentioned under point B.12 in MSR. Hostel. There is Remark that many residents were not staying in campus is baseless and neither was the deficiency against which this no Visitor Room, baseless remark is made without any proof, instead entire Occupancy List of Residents was handed over to Dr Mahesh Recreational Patel which he took with him when he went for inspection of Resident Hostels and Checked each and every one of them Room, Computer as captured in video as well. Also, each and every Resident is given allotment letter at their time of joining which is part of Room. Declaration Form taken by Assessor at time of Document Verification of Faculty & Residents. Annexure No.12 Residential Please see below deficiency as pointed out, Compliance submitted by Institute and Remarks of Assessor. Quarters: Deficiency: Item Number 20. Residential Quarters: Out of 16 quarters available for faculty, 10 are single room quarters. Compliance Submitted by Institute: As per MSR 14 Quarters are required, 14 nos., 2BHK quarter 10 nos., 1 room quarters are furnished and available. Remarks by Assessor: Deficiency not rectified. There are no proper teaching staff and non-teaching staff quarters available. One building was shown us which have single hostel type 10 rooms which are not counted as teaching staff quarters. In male resident hostel building 2nd & 3rd floor hostel rooms are shown as teaching staff quarters without kitchen which cannot be counted as teaching staff quarters. In 3rd building there are 6 quarters shown which have 2 rooms but no kitchen. There are 19 single hostel type rooms are shown as non-teaching staff quarters in the building of male nursing hostel which cannot accepted as non-teaching quarters. As submitted in our compliance submission, we state that there are total of 2rooms Quarters 14 in number is available and 1 Room Quarters 10 in number are available. The same has been admitted by the assessors in the report but a new deficiency

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In central Kitchen, no register showing diet supplied etc Laundry Equipment and Workload is less.

is created that these are not proper. It is nowhere mentioned in MSR that Quarters are to be 2BHK, 1 Room Quarter, or 3 BHK. A quarter as per definition is a housing facility provided by the employer to the employee. Against the requirement of 14 Quarters, we have total of 24 Quarters, most of which are occupied, occupancy list for same was handed over to the assessor on the day of Inspection and Assessor Dr Mahesh Patel personally checked each and every quarter personally whether Faculty is occupying the same. We have pictures and video of Dr Mahesh Patel checking the Faculty Quarters and their occupancy status. Please note that the quality of Faculty Quarters provided to the faculty with facilities of TV, Refrigerator, Attached Toilet, Furniture, Study Area which the faculty members are using happily and have no objection for same. If the people occupying the Housing Facility have no objection, then why is it classified as not proper is known best only to Assessor Dr Mahesh Patel and it signifies the ulterior motives. The remark for Non Teaching quarters is baseless and false as the same was neither the deficiency. It was noted in the SAF Report for Assessment carried on 7th January 2016 as 24 Numbers Available against requirement of 20, on page 10 under point 1.13. Hence No Deficiency Annexure No.2 & 15 For cross checking of Central Kitchen, it was never asked by the assessor Dr Mahesh Patel for Diet Supplied Register and this is neither a deficiency as pointed out in previous assessment nor a requirement any where in the MSR. The same was also not noted in SAF. Remarks are general in nature and bears no relevance, MOU, outsourced Laundry Services and Register of In House Laundry Service can be provided. Same was not brought to notice of Dean or signatures obtained anywhere regarding this deficiency. The same was not noted in SAF. Annexure No.16