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.

• Identify individuals at risk for suicide.
• The organization accepts for care, treatment, or services only those individuals whose identified care, treatment, or service needs it can meet. Note 1: For opioid treatment programs: If an individual eligible for treatment applies for admission to a comprehensive maintenance treatment program but cannot be placed within 14 days in a program that is within a reasonable geographic area, an opioid treatment program’s program sponsor may place the individual in interim maintenance treatment. Note 2: For opioid treatment programs: There may be individuals in special populations who have a history of opioid use but are not currently physiologically dependent. Federal regulations waive the one-year history of addiction for these special populations, because these individuals are susceptible to relapse to opioid addiction, leading to high-risk behaviors with potentially life-threatening consequences. These populations include the following: - Persons recently released from a penal institution - Persons recently discharged from a chronic care facility - Pregnant women - Previously treated patients
• The organization documents the discharge information of the individual served.
• The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.
• Identify individuals at risk for suicide.
• Leaders create and maintain a culture of safety and quality throughout the organization.
• Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement" [PI] chapter.)
• Qualified staff receive and record verbal orders. Note: Verbal orders may include medication, laboratory tests, dietary, or restraint and seclusion.
• Staff are competent to perform their job duties and responsibilities.
• Staff participate in education and training.
• The organization accepts for care, treatment, or services only those individuals whose identified care, treatment, or service needs it can meet. Note 1: For opioid treatment programs: If an individual eligible for treatment applies for admission to a comprehensive maintenance treatment program but cannot be placed within 14 days in a program that is within a reasonable geographic area, an opioid treatment program’s program sponsor may place the individual in interim maintenance treatment. Note 2: For opioid treatment programs: There may be individuals in special populations who have a history of opioid use but are not currently physiologically dependent. Federal regulations waive the one-year history of addiction for these special populations, because these individuals are susceptible to relapse to opioid addiction, leading to high-risk behaviors with potentially life-threatening consequences. These populations include the following: - Persons recently released from a penal institution - Persons recently discharged from a chronic care facility - Pregnant women - Previously treated patients
• The organization assesses the outcomes of care, treatment, or services provided to the individual served.
• The organization compiles and analyzes data.
• The organization documents the discharge information of the individual served.
• The organization evaluates the effectiveness of its medication management system. Note 1: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information) Note 2: This standard is applicable only to organizations that prescribe, dispense, or administer medications.
• 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 has an organizationwide, integrated safety program for individuals served.
• The organization manages safety and security risks.
• The organization provides orientation to staff.