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.

• A time-out is performed before the procedure.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Entries in the medical record are authenticated.
• Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• Medication orders are clear and accurate.
• Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
• Resuscitation services are available throughout the hospital.
• Staff and licensed independent practitioners performing waived tests are competent.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital addresses the safe use of look-alike/sound-alike medications.
• The hospital assesses and manages the patient's pain.
• The hospital assesses and manages the patient's risks for falls.
• The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
• The hospital compiles and analyzes data.
• The hospital complies with law and regulation.
• The hospital effectively manages the collection of health information.
• The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
• The hospital honors the patient's right to give or withhold informed consent.
• The hospital implements its infection prevention and control plan.
• The hospital improves performance on an ongoing basis.
• The hospital initiates restraint or seclusion based on an individual order.
• The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital inspects, tests, and maintains medical equipment.
• The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
• The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The hospital maintains complete and accurate medical records for each individual patient.
• The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital maintains the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital manages safety and security risks.
• The hospital monitors patients who are restrained or secluded.
• The hospital performs quality control checks for waived testing on each procedure. Note: Internal quality controls may include electronic, liquid, or control zone. External quality controls may include electronic or liquid.
• The hospital plans the patient’s care.
• The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects, protects, and promotes patient rights.
• The hospital safely dispenses medications.
• The hospital safely manages high-alert and hazardous medications.
• The hospital safely prepares medications.
• The hospital safely stores medications.
• The hospital traces all tissues bi-directionally.
• The management and coordination of each patient’s care, treatment, and services is the responsibility of a practitioner with appropriate privileges.
• The patient and his or her family have the right to have complaints reviewed by the hospital.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

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.

• A time-out is performed before the procedure.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Entries in the medical record are authenticated.
• Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• Medication orders are clear and accurate.
• Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
• Resuscitation services are available throughout the hospital.
• Staff and licensed independent practitioners performing waived tests are competent.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital addresses the safe use of look-alike/sound-alike medications.
• The hospital assesses and manages the patient's pain.
• The hospital assesses and manages the patient's risks for falls.
• The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
• The hospital compiles and analyzes data.
• The hospital complies with law and regulation.
• The hospital effectively manages the collection of health information.
• The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
• The hospital honors the patient's right to give or withhold informed consent.
• The hospital implements its infection prevention and control plan.
• The hospital improves performance on an ongoing basis.
• The hospital initiates restraint or seclusion based on an individual order.
• The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital inspects, tests, and maintains medical equipment.
• The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
• The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The hospital maintains complete and accurate medical records for each individual patient.
• The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital maintains the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital manages safety and security risks.
• The hospital monitors patients who are restrained or secluded.
• The hospital performs quality control checks for waived testing on each procedure. Note: Internal quality controls may include electronic, liquid, or control zone. External quality controls may include electronic or liquid.
• The hospital plans the patient’s care.
• The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects, protects, and promotes patient rights.
• The hospital safely dispenses medications.
• The hospital safely manages high-alert and hazardous medications.
• The hospital safely prepares medications.
• The hospital safely stores medications.
• The hospital traces all tissues bi-directionally.
• The management and coordination of each patient’s care, treatment, and services is the responsibility of a practitioner with appropriate privileges.
• The patient and his or her family have the right to have complaints reviewed by the hospital.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

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.

• A time-out is performed before the procedure.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Entries in the medical record are authenticated.
• Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• Medication orders are clear and accurate.
• Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
• Resuscitation services are available throughout the hospital.
• Staff and licensed independent practitioners performing waived tests are competent.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital addresses the safe use of look-alike/sound-alike medications.
• The hospital assesses and manages the patient's pain.
• The hospital assesses and manages the patient's risks for falls.
• The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
• The hospital compiles and analyzes data.
• The hospital complies with law and regulation.
• The hospital effectively manages the collection of health information.
• The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
• The hospital honors the patient's right to give or withhold informed consent.
• The hospital implements its infection prevention and control plan.
• The hospital improves performance on an ongoing basis.
• The hospital initiates restraint or seclusion based on an individual order.
• The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital inspects, tests, and maintains medical equipment.
• The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
• The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The hospital maintains complete and accurate medical records for each individual patient.
• The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital maintains the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital manages safety and security risks.
• The hospital monitors patients who are restrained or secluded.
• The hospital performs quality control checks for waived testing on each procedure. Note: Internal quality controls may include electronic, liquid, or control zone. External quality controls may include electronic or liquid.
• The hospital plans the patient’s care.
• The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects, protects, and promotes patient rights.
• The hospital safely dispenses medications.
• The hospital safely manages high-alert and hazardous medications.
• The hospital safely prepares medications.
• The hospital safely stores medications.
• The hospital traces all tissues bi-directionally.
• The management and coordination of each patient’s care, treatment, and services is the responsibility of a practitioner with appropriate privileges.
• The patient and his or her family have the right to have complaints reviewed by the hospital.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.