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.

• Any individual who provides care, treatment, or services can report concerns about safety or the quality of care to The Joint Commission without retaliatory action from the organization.
• Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
• Before the organization discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, or services.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• Care, treatment, or services provided through contractual agreement are provided safely and effectively.
• Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
• Governance is ultimately accountable for the safety and quality of care, treatment, or services.
• Mark the procedure site.
• The organization addresses the safe use of look-alike/sound-alike medications.
• The organization defines staff qualifications.
• The organization establishes and maintains a safe, functional environment.
• The organization evaluates the effectiveness of its infection prevention and control activities.
• The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
• The organization implements infection prevention and control activities.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations 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 organization inspects, tests, and maintains medical equipment.
• The organization inspects, tests, and maintains medical gas and vacuum systems. Note 1: This standard does not require organizations to have the medical gas and vacuum systems discussed below. However, if an organization has these types of systems, then the following inspection, testing, and maintenance requirements apply. Note 2: Piped medical gas systems include oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, instrument air and mixtures thereof. Piped vacuum systems include both medical-surgical vacuum and waste anesthetic gas disposal (WAGD) systems.
• The organization inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, organizations are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The organization maintains fire safety equipment and fire safety building features. Note: This standard does not require organizations 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 organization maintains records for waived testing.
• The organization manages risks associated with its utility systems.
• The organization manages risks related to hazardous materials and waste.
• The organization provides and maintains equipment for extinguishing fires. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
• The organization provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization respects the patient's right to receive information in a manner he or she understands.
• The organization safely manages high-alert and hazardous medications.
• The organization safely stores medications.
• Any individual who provides care, treatment, or services can report concerns about safety or the quality of care to The Joint Commission without retaliatory action from the organization.
• Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
• Before the organization discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, or services.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• Care, treatment, or services provided through contractual agreement are provided safely and effectively.
• Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
• Governance is ultimately accountable for the safety and quality of care, treatment, or services.
• Mark the procedure site.
• The organization addresses the safe use of look-alike/sound-alike medications.
• The organization defines staff qualifications.
• The organization establishes and maintains a safe, functional environment.
• The organization evaluates the effectiveness of its infection prevention and control activities.
• The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
• The organization implements infection prevention and control activities.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations 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 organization inspects, tests, and maintains medical equipment.
• The organization inspects, tests, and maintains medical gas and vacuum systems. Note 1: This standard does not require organizations to have the medical gas and vacuum systems discussed below. However, if an organization has these types of systems, then the following inspection, testing, and maintenance requirements apply. Note 2: Piped medical gas systems include oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, instrument air and mixtures thereof. Piped vacuum systems include both medical-surgical vacuum and waste anesthetic gas disposal (WAGD) systems.
• The organization inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, organizations are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The organization maintains fire safety equipment and fire safety building features. Note: This standard does not require organizations 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 organization maintains records for waived testing.
• The organization manages risks associated with its utility systems.
• The organization manages risks related to hazardous materials and waste.
• The organization provides and maintains equipment for extinguishing fires. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
• The organization provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization respects the patient's right to receive information in a manner he or she understands.
• The organization safely manages high-alert and hazardous medications.
• The organization safely stores medications.

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.

• Any individual who provides care, treatment, or services can report concerns about safety or the quality of care to The Joint Commission without retaliatory action from the organization.
• Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
• Before the organization discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, or services.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• Care, treatment, or services provided through contractual agreement are provided safely and effectively.
• Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
• Governance is ultimately accountable for the safety and quality of care, treatment, or services.
• Mark the procedure site.
• The organization addresses the safe use of look-alike/sound-alike medications.
• The organization defines staff qualifications.
• The organization establishes and maintains a safe, functional environment.
• The organization evaluates the effectiveness of its infection prevention and control activities.
• The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
• The organization implements infection prevention and control activities.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations 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 organization inspects, tests, and maintains medical equipment.
• The organization inspects, tests, and maintains medical gas and vacuum systems. Note 1: This standard does not require organizations to have the medical gas and vacuum systems discussed below. However, if an organization has these types of systems, then the following inspection, testing, and maintenance requirements apply. Note 2: Piped medical gas systems include oxygen, nitrous oxide, medical air, carbon dioxide, helium, nitrogen, instrument air and mixtures thereof. Piped vacuum systems include both medical-surgical vacuum and waste anesthetic gas disposal (WAGD) systems.
• The organization inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, organizations are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The organization maintains fire safety equipment and fire safety building features. Note: This standard does not require organizations 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 organization maintains records for waived testing.
• The organization manages risks associated with its utility systems.
• The organization manages risks related to hazardous materials and waste.
• The organization provides and maintains equipment for extinguishing fires. Note 1: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render patients incapable of saving themselves in an emergency in the organization. Note 2: This standard applies to all ambulatory surgical centers seeking accreditation for Medicare certification purposes, regardless of the number of patients rendered incapable. Note 3: In leased facilities, the elements of performance of this standard apply only to the space in which the accredited organization is located; all exits from the space to the outside at grade level; and any Life Safety Code building systems that support the space (for example, fire alarm system, automatic sprinkler system).
• The organization provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
• The organization provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization respects the patient's right to receive information in a manner he or she understands.
• The organization safely manages high-alert and hazardous medications.
• The organization safely stores medications.