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.

• The hospital defines and verifies staff qualifications.
• The hospital makes food and nutrition products available to its patients.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• 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.
• Medication orders are clear and accurate.
• 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 information to monitor conditions in the environment.
• The hospital conducts fire drills.
• The hospital defines and verifies staff qualifications.
• The hospital effectively manages the collection of health information.
• 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 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 maintains the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages fire risks.
• The hospital manages risks associated with its utility systems.
• The hospital manages safety and security risks.
• 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 systems for extinguishing fires.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects the patient's right to receive information in a manner he or she understands.
• The hospital uses restraint or seclusion safely.

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 pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• 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.
• Medication orders are clear and accurate.
• 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 information to monitor conditions in the environment.
• The hospital conducts fire drills.
• The hospital defines and verifies staff qualifications.
• The hospital effectively manages the collection of health information.
• 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 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 maintains the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages fire risks.
• The hospital manages risks associated with its utility systems.
• The hospital manages safety and security risks.
• 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 systems for extinguishing fires.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects the patient's right to receive information in a manner he or she understands.
• The hospital uses restraint or seclusion safely.