The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

• Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
• Reduce the risk for suicide. Note: EPs 2–7 apply to patients in psychiatric hospitals or patients being evaluated or treated for behavioral health conditions as their primary reason for care. In addition, EPs 3–7 apply to all patients who express suicidal ideation during the course of care.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital documents the use of restraint or seclusion.
• The hospital evaluates and reevaluates the patient who is restrained or secluded.
• The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.
• The hospital has policies and procedures that guide and support patient care, treatment, and services.
• The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety.”
• The nurse executive directs the hospital’s nursing services.
• The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.
• Those who work in the hospital are focused on improving safety and quality.