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 that serve adults with serious mental illness: The organization supports the adult’s decisions (psychiatric advance directive) about how care, treatment, or services are to be delivered during times when he or she is unable to make such decisions. (See also RI.01.05.01, EPs 1, 4, 5, 8, 10)
• Reduce the risk for suicide.
• 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 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 provides orientation to staff.
• The organization screens all individuals served for their nutritional status.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note: The elements of performance of this standard apply only to the space in which the hospice unit is located, all exits from the unit to the outside at grade level, and any Life Safety Code building systems that support the unit (for example, fire alarm system, automatic sprinkler system).
• Education and training in aseptic manipulation skills for sterile compounding includes testing of technique and demonstration of competency. (For more information, refer to Standards HR.01.05.03 and HR.01.07.01)
• The organization implements the infection prevention and control activities it has planned.
• The organization maintains complete and accurate patient records.
• The organization plans the patient’s care.
• The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation.
• The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
• The organization safely stores medications.
• A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
• A time-out is performed before the procedure.
• Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Entries in the medical record are authenticated.
• Reduce the risk for suicide. Note: EPs 2–7 apply only to patients in psychiatric hospitals and patients being evaluated or treated for behavioral health conditions as their primary reason for care in general hospitals.
• Resuscitation services are available throughout the hospital.
• Staff are competent to perform their responsibilities.
• The hospital assesses and manages the patient's risks for falls.
• The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.
• The hospital assesses and reassesses its patients.
• The hospital assesses the needs of patients who receive psychosocial services to treat alcoholism or other substance use disorders.
• The hospital assesses the patient who may be a victim of possible abuse and neglect.
• The hospital conducts fire drills.
• The hospital defines and verifies staff qualifications.
• The hospital designs and manages the physical environment to comply with the Life Safety Code.
• 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 has a reliable emergency electrical power source.
• The hospital has policies and procedures that guide and support patient care, treatment, and services.
• 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 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 fire risks.
• The hospital manages medical equipment risks.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital plans the patient’s care.
• The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains fire alarm systems.
• 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 for each patient.
• The hospital 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 hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital safely administers medications.
• The hospital safely stores medications.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.