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.
- Care, treatment, or services provided through contractual agreement are provided safely and effectively.
- For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.
- Staff performing waived tests are competent.
- The organization assesses the outcomes of care, treatment, or services provided to the individual served.
- The organization collects data to monitor its performance.
- The organization compiles and analyzes data.
- The organization conducts fire drills.
- The organization develops written job descriptions.
- The organization effectively manages its programs or services.
- The organization establishes and maintains a safe, functional environment.
- The organization evaluates staff performance.
- The organization evaluates the effectiveness of its Emergency Management Plan.
- The organization evaluates the effectiveness of its infection prevention and control plan.
- The organization facilitates staff receiving the influenza vaccination.
Note: This standard is not applicable to staff providing care, treatment, or services off site through telephone consultation or technology-based services.
- 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 risks for acquiring and spreading infections.
- The organization implements its infection prevention and control plan.
- 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 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 egress.
Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 17 or more 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 manages its space during demolition, renovation, or new construction.
Note: These elements of performance are applicable to all occupancy types.
- The organization manages safety and security risks.
- The organization 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 organization protects occupants during periods when the Life Safety Code is not met or during periods of construction.
Note: This standard applies to behavioral health care settings that provide sleeping arrangements for four or more individuals served as a required part of their care, treatment, or services.
- The organization provides orientation to staff.
- The organization verifies and evaluates staff qualifications.
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