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.
• Hospital leaders allocate needed resources for the infection prevention and control program.
• Medication orders are clear and accurate.
• Resuscitation services are available throughout the hospital.
• Staff participate in ongoing education and training.
• The hospital addresses the safe use of look-alike/sound-alike medications.
• The hospital conducts fire drills.
• The hospital effectively communicates with patients when providing care, treatment, and services.
• 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 honors the patient's right to give or withhold informed consent.
• The hospital identifies risks for acquiring and transmitting infections.
• The hospital implements its infection prevention and control plan.
• The hospital inspects, tests, and maintains medical equipment.
• 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 the integrity of the means of egress.
• The hospital makes space and equipment available as needed for the provision of care, treatment, and services.
• The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• 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 systems for extinguishing fires.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital safely prepares medications.
• The hospital safely stores medications.
• The medical record contains information that reflects the patient's care, treatment, and services.
• Those who work in the hospital are focused on improving safety and quality.

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.
• Hospital leaders allocate needed resources for the infection prevention and control program.
• Medication orders are clear and accurate.
• Resuscitation services are available throughout the hospital.
• Staff participate in ongoing education and training.
• The hospital addresses the safe use of look-alike/sound-alike medications.
• The hospital conducts fire drills.
• The hospital effectively communicates with patients when providing care, treatment, and services.
• 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 honors the patient's right to give or withhold informed consent.
• The hospital identifies risks for acquiring and transmitting infections.
• The hospital implements its infection prevention and control plan.
• The hospital inspects, tests, and maintains medical equipment.
• 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 the integrity of the means of egress.
• The hospital makes space and equipment available as needed for the provision of care, treatment, and services.
• The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• 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 systems for extinguishing fires.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital safely prepares medications.
• The hospital safely stores medications.
• The medical record contains information that reflects the patient's care, treatment, and services.
• Those who work in the hospital are focused on improving safety and quality.