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.

• For organizations that use restraint or seclusion: A licensed independent practitioner orders the use of restraint or seclusion. Note: This standard is not to be construed to limit the authority of a doctor of medicine or osteopathy to delegate tasks to physician assistants and advanced practice nurses to the extent recognized under state law or a state’s regulatory mechanism and allowed by the organization.
• Qualified staff receive and record verbal orders. Note: Verbal orders may include medication, laboratory tests, dietary, or restraint and seclusion.
• The organization assesses the outcomes of care, treatment, or services provided to the individual served.
• The organization effectively manages its programs or services.
• The organization evaluates the effectiveness of its Emergency Management Plan.
• The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.
• The organization implements its infection prevention and control plan.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations to have the types of emergency power equipment described in the elements of performance of this standard. However, if these types of emergency equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. This does not apply to generators used only for convenience purposes.
• The organization manages risks associated with its utility systems.
• The organization 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 organization screens all individuals served for their nutritional status.
• Use at least two identifiers when providing care, treatment, or services. Note: Treatments covered by this goal include high-risk interventions and certain high risk medications (for example, methadone). In some settings, use of visual recognition as an identifier is acceptable. Such settings include those that regularly serve an individual (for example, therapy) or serve only a few individuals (for example, a group home). These are settings in which the individual stays for an extended period of time, staff and populations served are stable, and individuals receiving care are well-known to staff.
• 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.
• 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.
• Staff and licensed independent practitioners performing waived tests are competent.
• Staff are competent to perform their responsibilities.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.
• The hospital assesses and reassesses its patients.
• The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
• The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
• The hospital collects data to monitor its performance.
• The hospital defines and verifies staff qualifications.
• The hospital documents the patient’s discharge information.
• The hospital effectively manages its programs, services, sites, or departments.
• 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 evaluates and reevaluates the patient who is restrained or secluded.
• The hospital evaluates the effectiveness of its Emergency Operations Plan.
• The hospital has a reliable emergency electrical power source.
• The hospital has an antimicrobial stewardship program based on current scientific literature.
• The hospital has policies and procedures that guide and support patient care, treatment, and services.
• The hospital implements its infection prevention and control plan.
• 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 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 manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• 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 features to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains fire alarm systems.
• 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 uses restraint or seclusion safely.
• The medical record contains information that reflects the patient's care, treatment, and services.