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.

• Identify individuals at risk for suicide.
• Staff are competent to perform their job duties and responsibilities.
• The organization compiles and analyzes data.
• The organization coordinates the care, treatment, or services provided to an individual served as part of the plan for care, treatment, or services and in a manner consistent with the organization's scope of care, treatment, or services. (For more information, refer to Standard CTS.03.01.07.)
• The organization has a reliable emergency electrical power source.
• 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.
• A complete and accurate assessment drives the identification and delivery of the care, treatment, or services needed by the individual served.
• Documentation in the clinical/case record is entered in a timely manner.
• Entries in the clinical/case record are authenticated.
• For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products.
• For organizations that do not operate a pharmacy but administer medications: The organization safely obtains prescribed medications.
• Identify individuals at risk for suicide.
• Leaders create and maintain a culture of safety and quality throughout the organization.
• Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement" [PI] chapter.)
• Leaders use organizationwide planning to establish structures and processes that focus on safety and quality.
• Maintain and communicate accurate medication information for the individual served.
• Medication orders are clear and accurate. Note: This standard is applicable only to organizations that prescribe medications. The elements of performance in this standard do not apply to prescriptions written by a prescriber who is not affiliated with the organization.
• Staff are competent to perform their job duties and responsibilities.
• The mission, vision, and goals of the organization support the safety and quality of care, treatment, or services.
• The organization assesses the outcomes of care, treatment, or services provided to the individual served.
• 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 collects data to monitor its performance.
• The organization compiles and analyzes data.
• The organization conducts fire drills.
• The organization coordinates the care, treatment, or services provided to an individual served as part of the plan for care, treatment, or services and in a manner consistent with the organization's scope of care, treatment, or services. (For more information, refer to Standard CTS.03.01.07.)
• The organization designs and manages the physical environment to comply with the Life Safety Code. 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 evaluates staff performance.
• The organization evaluates the effectiveness of its Emergency Management Plan.
• The organization evaluates the effectiveness of its medication management system. Note 1: This evaluation includes reconciling medication information. (Refer to NPSG.03.06.01 for more information) Note 2: This standard is applicable only to organizations that prescribe, dispense, or administer medications.
• 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 has a reliable emergency electrical power source.
• 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 escape. Note 1: This standard applies to small 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 safety and security risks.
• The organization screens all individuals served for their nutritional status.
• The organization verifies and evaluates staff qualifications.