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.
• For organizations that use restraint or seclusion: A licensed independent practitioner sees and evaluates the individual in restraint or seclusion in person.
• Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
• For organizations that use physical holding on a child or youth: Physical holding of children and youth is used in a safe manner.
• For organizations that use physical holding on a child or youth: The leaders establish and communicate the organization’s philosophy on physical holding of children or youth.
• For organizations that use physical holding on a child or youth: The organization collects data on the use of physical holding.
• Staff who provide care, treatment, or services to children or youth have specific competencies.
• The clinical/case record contains information that reflects the care, treatment, or services provided to the individual served.
• The individual served has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.
• The organization collects data to monitor its performance.
• 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 improves its environment of care.
• The organization maintains complete and accurate clinical/case records.
• The organization provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
• The organization respects the rights of the individual served.
• The organization safely stores medications. Note: This standard is applicable only to organizations that store medications at their sites.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital reports deaths associated with the use of restraint and seclusion.
• 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.
• Leaders create and maintain a culture of safety and quality throughout the hospital.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• 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 complies with law and regulation.
• The hospital documents the use of restraint or seclusion.
• 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 medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information)
• The hospital maintains complete and accurate medical records for each individual patient.
• The hospital maintains the integrity of the means of egress.
• The hospital maintains the security and integrity of health information.
• The hospital manages fire risks.
• The hospital manages risks associated with its utility systems.
• The hospital plans the patient’s care.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
• The hospital respects the patient's right to receive information in a manner he or she understands.
• The hospital responds to actual or potential adverse drug events, significant adverse drug reactions, and medication errors.
• The hospital trains staff to safely implement the use of restraint or seclusion.
• The hospital verifies staff qualifications.
• The medical record contains information that reflects the patient's care, treatment, and services.
• The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.

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.
• For organizations that use restraint or seclusion: A licensed independent practitioner sees and evaluates the individual in restraint or seclusion in person.
• Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
• For organizations that use physical holding on a child or youth: Physical holding of children and youth is used in a safe manner.
• For organizations that use physical holding on a child or youth: The leaders establish and communicate the organization’s philosophy on physical holding of children or youth.
• For organizations that use physical holding on a child or youth: The organization collects data on the use of physical holding.
• Staff who provide care, treatment, or services to children or youth have specific competencies.
• The clinical/case record contains information that reflects the care, treatment, or services provided to the individual served.
• The individual served has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.
• The organization collects data to monitor its performance.
• 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 improves its environment of care.
• The organization maintains complete and accurate clinical/case records.
• The organization provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
• The organization respects the rights of the individual served.
• The organization safely stores medications. Note: This standard is applicable only to organizations that store medications at their sites.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital reports deaths associated with the use of restraint and seclusion.
• 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.
• Leaders create and maintain a culture of safety and quality throughout the hospital.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• 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 complies with law and regulation.
• The hospital documents the use of restraint or seclusion.
• 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 medication management system. Note: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information)
• The hospital maintains complete and accurate medical records for each individual patient.
• The hospital maintains the integrity of the means of egress.
• The hospital maintains the security and integrity of health information.
• The hospital manages fire risks.
• The hospital manages risks associated with its utility systems.
• The hospital plans the patient’s care.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
• The hospital respects the patient's right to receive information in a manner he or she understands.
• The hospital responds to actual or potential adverse drug events, significant adverse drug reactions, and medication errors.
• The hospital trains staff to safely implement the use of restraint or seclusion.
• The hospital verifies staff qualifications.
• The medical record contains information that reflects the patient's care, treatment, and services.
• The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.