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.

• Staff are competent to perform their job duties and responsibilities.
• The organization establishes and maintains a safe, functional environment.
• 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 identifies individuals served who may have experienced trauma, abuse, neglect, or exploitation.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations to have the types of emergency power equipment described in the elements of performance of this standard. However, if these types of emergency equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. This does not apply to generators used only for convenience purposes.
• The organization maintains and protects vertical openings, fire alarm systems, and separation of sleeping rooms. Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 4 to 16 individuals served as a required part of their care, treatment, or services. Note 2: If the organization locks doors so that individuals served are prohibited from leaving the building or space, then Standards LS.02.01.10 through LS.02.01.70 apply.
• 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 in the elements of performance of this standard. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The organization manages risks associated with its utility systems.
• The organization notifies the public it serves about how to contact its organization management and The Joint Commission to report concerns about safety of the individual served and quality of care. Note: Methods of notice may include, but are not limited to, distribution of information about The Joint Commission, including contact information in published materials such as brochures and/or posting this information on the organization's website.
• The organization screens all individuals served for their nutritional status. Note: Triggers for a nutritional assessment may include a weight loss or weight gain of 10 pounds or more in the past three months, a change in appetite, dental problems, noncompliance with a special diet, and food allergies. (Refer to CTS.02.03.09, EP 1 for more information)
• The organization verifies and evaluates staff qualifications.
• For organizations providing care, treatment, or services to individuals with addictions: The assessment includes the individual's history of addictive behaviors.
• For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.
• Identify individuals at risk for suicide.
• Staff are competent to perform their job duties and responsibilities.
• 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 organization audits its clinical/case records.
• The organization bases the planned care, treatment, or services on the needs, strengths, preferences, and goals of the individual served. Note: For opioid treatment programs: Methadone has well-documented effects on several systems, including the respiratory, nervous, and cardiac systems, and the liver. Additionally, many medications including methadone can act to increase the QT interval on an electrocardiogram and potentially lead to torsades de pointes, a potentially life-threatening cardiac arrhythmia. Therefore, it is important for the program physician to consider all of the medications the patient is currently taking (including actual versus prescribed doses, illicit drugs, medically active adulterants potentially present in illicit substances, and medically active over-the-counter or natural remedies). Given consideration of this information, the program physician can determine whether the treatment drug will be methadone, buprenorphine, or another medication and whether the treatment indicated for the patient is induction, detoxification, or maintenance.
• The organization complies with law and regulation.
• The organization conducts fire drills.
• The organization develops written job descriptions.
• The organization establishes and maintains a safe, functional environment.
• The organization evaluates the effectiveness of its Emergency Management Plan.
• 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 identifies individuals served who may have experienced trauma, abuse, neglect, or exploitation.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations to have the types of emergency power equipment described in the elements of performance of this standard. However, if these types of emergency equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. This does not apply to generators used only for convenience purposes.
• The organization maintains and protects vertical openings, fire alarm systems, and separation of sleeping rooms. Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 4 to 16 individuals served as a required part of their care, treatment, or services. Note 2: If the organization locks doors so that individuals served are prohibited from leaving the building or space, then Standards LS.02.01.10 through LS.02.01.70 apply.
• 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 in the elements of performance of this standard. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The organization maintains the integrity of the means of escape. Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 4 to 16 individuals served as a required part of their care, treatment, or services. Note 2: If the organization locks doors so that individuals served are prohibited from leaving the building or space, then Standards LS.02.01.10 through LS.02.01.70 apply. Note 3: See Standard EC.02.03.03 for fire drill requirements.
• The organization manages fire risks.
• The organization manages risks associated with its utility systems.
• The organization manages risks related to hazardous materials.
• The organization notifies the public it serves about how to contact its organization management and The Joint Commission to report concerns about safety of the individual served and quality of care. Note: Methods of notice may include, but are not limited to, distribution of information about The Joint Commission, including contact information in published materials such as brochures and/or posting this information on the organization's website.
• The organization provides orientation to staff.
• The organization safely stores medications. Note: This standard is applicable only to organizations that store medications at their sites.
• The organization screens all individuals served for their nutritional status. Note: Triggers for a nutritional assessment may include a weight loss or weight gain of 10 pounds or more in the past three months, a change in appetite, dental problems, noncompliance with a special diet, and food allergies. (Refer to CTS.02.03.09, EP 1 for more information)
• The organization verifies and evaluates staff qualifications.
• When an individual served is transferred or discharged, the continuity of care, treatment, or services is maintained.

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 providing care, treatment, or services to individuals with addictions: The assessment includes the individual's history of addictive behaviors.
• For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.
• Identify individuals at risk for suicide.
• Staff are competent to perform their job duties and responsibilities.
• 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 organization audits its clinical/case records.
• The organization bases the planned care, treatment, or services on the needs, strengths, preferences, and goals of the individual served. Note: For opioid treatment programs: Methadone has well-documented effects on several systems, including the respiratory, nervous, and cardiac systems, and the liver. Additionally, many medications including methadone can act to increase the QT interval on an electrocardiogram and potentially lead to torsades de pointes, a potentially life-threatening cardiac arrhythmia. Therefore, it is important for the program physician to consider all of the medications the patient is currently taking (including actual versus prescribed doses, illicit drugs, medically active adulterants potentially present in illicit substances, and medically active over-the-counter or natural remedies). Given consideration of this information, the program physician can determine whether the treatment drug will be methadone, buprenorphine, or another medication and whether the treatment indicated for the patient is induction, detoxification, or maintenance.
• The organization complies with law and regulation.
• The organization conducts fire drills.
• The organization develops written job descriptions.
• The organization establishes and maintains a safe, functional environment.
• The organization evaluates the effectiveness of its Emergency Management Plan.
• 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 identifies individuals served who may have experienced trauma, abuse, neglect, or exploitation.
• The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations to have the types of emergency power equipment described in the elements of performance of this standard. However, if these types of emergency equipment exist within the building, then the following maintenance, testing, and inspection requirements apply. This does not apply to generators used only for convenience purposes.
• The organization maintains and protects vertical openings, fire alarm systems, and separation of sleeping rooms. Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 4 to 16 individuals served as a required part of their care, treatment, or services. Note 2: If the organization locks doors so that individuals served are prohibited from leaving the building or space, then Standards LS.02.01.10 through LS.02.01.70 apply.
• 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 in the elements of performance of this standard. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The organization maintains the integrity of the means of escape. Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 4 to 16 individuals served as a required part of their care, treatment, or services. Note 2: If the organization locks doors so that individuals served are prohibited from leaving the building or space, then Standards LS.02.01.10 through LS.02.01.70 apply. Note 3: See Standard EC.02.03.03 for fire drill requirements.
• The organization manages fire risks.
• The organization manages risks associated with its utility systems.
• The organization manages risks related to hazardous materials.
• The organization notifies the public it serves about how to contact its organization management and The Joint Commission to report concerns about safety of the individual served and quality of care. Note: Methods of notice may include, but are not limited to, distribution of information about The Joint Commission, including contact information in published materials such as brochures and/or posting this information on the organization's website.
• The organization provides orientation to staff.
• The organization safely stores medications. Note: This standard is applicable only to organizations that store medications at their sites.
• The organization screens all individuals served for their nutritional status. Note: Triggers for a nutritional assessment may include a weight loss or weight gain of 10 pounds or more in the past three months, a change in appetite, dental problems, noncompliance with a special diet, and food allergies. (Refer to CTS.02.03.09, EP 1 for more information)
• The organization verifies and evaluates staff qualifications.
• When an individual served is transferred or discharged, the continuity of care, treatment, or services is maintained.