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.
- Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
- Medications are labeled.
Note: This standard is applicable to all organizations that prepare and administer medications.
- Staff and licensed independent practitioners performing waived tests are competent.
- The organization addresses the safe use of look-alike/sound-alike medications.
- The organization collects information to monitor conditions in the environment.
- The organization evaluates the effectiveness of its Emergency Management Plan.
- The organization evaluates the effectiveness of its infection prevention and control activities.
- The organization identifies risks for acquiring and transmitting infections.
- The organization inspects, tests, and maintains medical equipment.
- The organization maintains fire safety equipment and fire safety building features.
Note: This standard does not require organizations 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 organization manages fire risks.
- The organization manages medical equipment risks.
- The organization manages risks related to hazardous materials and waste.
- The organization manages safety and security risks.
- The organization offers vaccination against influenza to licensed independent practitioners and staff.
Note: This standard is applicable to staff and licensed independent practitioners only when care, treatment, or services are provided on site. When care, treatment, or services are provided off site, such as with telemedicine or telephone consultation, this standard is not applicable to off-site staff and licensed independent practitioners.
- 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 provides patient education and training based on each patient’s needs and abilities.
- The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
- The organization reports any changes in the information provided in the application for accreditation and any changes made between surveys.
- The organization safely manages emergency medications.
- The organization safely manages high-alert and hazardous medications.
- The organization safely stores medications.
- Use at least two patient identifiers when providing care, treatment, or services.