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.

• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. Note 1: This standard applies to ambulatory health care occupancy (AHCO) classification requirements for hospitals. The application of AHCO in a hospital would need to meet one of the following provisions: multiple occupancies (18/19.1.3), contiguous non–health care occupancy (18/19.1.3.4), separated building occupancies (20/21.1.2). Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: This standard applies to outpatient surgical departments associated with hospitals, 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).
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Reduce the risk for suicide. Note: EPs 2–7 apply to patients in psychiatric hospitals or patients being evaluated or treated for behavioral health conditions as their primary reason for care. In addition, EPs 3–7 apply to all patients who express suicidal ideation during the course of care.
• Resuscitative services are available throughout the hospital.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• 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 collects information to monitor conditions in the environment.
• The hospital conducts fire drills.
• The hospital designs and manages the physical environment to comply with the Life Safety Code.
• The hospital effectively manages its programs, services, sites, or departments.
• 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 a water management program that addresses Legionella and other waterborne pathogens. Note: The water management program is in accordance with law and regulation.
• 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 identifies the individual(s) responsible for the infection prevention and control program.
• The hospital implements its infection prevention and control plan.
• The hospital initiates restraint or seclusion based on an individual order.
• 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 equipment.
• 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 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. Note 1: This standard applies to ambulatory health care occupancy (AHCO) classification requirements for hospitals. The application of AHCO in a hospital would need to meet one of the following provisions: multiple occupancies (18/19.1.3), contiguous non–health care occupancy (18/19.1.3.4), separated building occupancies (20/21.1.2). Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: This standard applies to outpatient surgical departments associated with hospitals, 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 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 its environment during demolition, renovation, or new construction to reduce risk to those in the organization.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.
• The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. Note 1: This standard applies to ambulatory health care occupancy (AHCO) classification requirements for hospitals. The application of AHCO in a hospital would need to meet one of the following provisions: multiple occupancies (18/19.1.3), contiguous non–health care occupancy (18/19.1.3.4), separated building occupancies (20/21.1.2). Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: This standard applies to outpatient surgical departments associated with hospitals, 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 hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains building services to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains equipment for extinguishing fires. Note 1: This standard applies to ambulatory health care occupancy (AHCO) classification requirements for hospitals. The application of AHCO in a hospital would need to meet one of the following provisions: multiple occupancies (18/19.1.3), contiguous non–health care occupancy (18/19.1.3.4), separated building occupancies (20/21.1.2). Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: This standard applies to outpatient surgical departments associated with hospitals, 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 hospital provides and maintains fire alarm systems. Note 1: This standard applies to ambulatory health care occupancy (AHCO) classification requirements for hospitals. The application of AHCO in a hospital would need to meet one of the following provisions: multiple occupancies (18/19.1.3), contiguous non–health care occupancy (18/19.1.3.4), separated building occupancies (20/21.1.2). Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: This standard applies to outpatient surgical departments associated with hospitals, 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 hospital provides and maintains fire alarm systems.
• The hospital provides and maintains operating features that conform to fire and smoke prevention requirements.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety.”
• 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 manages emergency medications.
• The hospital safely prepares medications.
• The hospital traces all tissues bi-directionally.
• The hospital uses standardized procedures for managing tissues.

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.

• Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.

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.

• Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.