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 implements its infection prevention and control plan.
• The hospital maintains the integrity of the means of egress.
• The hospital provides and maintains systems for extinguishing fires.
• Medication orders are clear and accurate.
• Resuscitation services are available throughout the hospital.
• Staff are competent to perform their responsibilities.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital conducts fire drills.
• The hospital designs and manages the physical environment to comply with the Life Safety Code.
• 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 implements its infection prevention and control plan.
• 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 medical equipment.
• The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance 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 maintains the security and integrity of health information.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital manages safety and security risks.
• The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
• 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 verifies staff qualifications.

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.

• Medication orders are clear and accurate.
• Resuscitation services are available throughout the hospital.
• Staff are competent to perform their responsibilities.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital conducts fire drills.
• The hospital designs and manages the physical environment to comply with the Life Safety Code.
• 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 implements its infection prevention and control plan.
• 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 medical equipment.
• The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance 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 maintains the security and integrity of health information.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital manages safety and security risks.
• The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
• 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 verifies staff qualifications.