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.

• The organization assesses and reassesses its patients.
• The organization engages in planning activities prior to developing its written Emergency Operations Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
• The organization implements the infection prevention and control activities it has planned.
• The organization plans the patient’s care.
• The organization provides and maintains systems for extinguishing fires. 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).
• The organization safely manages high-alert and hazardous medications.
• 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.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Hospital leaders allocate needed resources for the infection prevention and control program.
• Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• Staff are competent to perform their responsibilities.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital analyzes identified environment of care issues.
• 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 data to monitor its performance.
• 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 evaluates and reevaluates the patient who is restrained or secluded.
• The hospital evaluates the effectiveness of its Emergency Operations Plan.
• The hospital has a reliable emergency electrical power source.
• The hospital has an Emergency Operations Plan. Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This "all hazards" approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
• The hospital has an infection prevention and control plan.
• The hospital honors the patient's right to give or withhold informed consent.
• 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 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 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 makes food and nutrition products available to its patients.
• The hospital manages fire risks.
• 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 manages safety and security risks.
• 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 operating features that conform to fire and smoke prevention requirements.
• 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, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
• 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 medical record contains information that reflects the patient's care, treatment, and services.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
• Those who work in the hospital are focused on improving safety and quality.

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 organization assesses and reassesses its patients.
• The organization engages in planning activities prior to developing its written Emergency Operations Plan. Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
• The organization implements the infection prevention and control activities it has planned.
• The organization plans the patient’s care.
• The organization provides and maintains systems for extinguishing fires. 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).
• The organization safely manages high-alert and hazardous medications.
• 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.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Hospital leaders allocate needed resources for the infection prevention and control program.
• Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• Staff are competent to perform their responsibilities.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital analyzes identified environment of care issues.
• 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 data to monitor its performance.
• 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 evaluates and reevaluates the patient who is restrained or secluded.
• The hospital evaluates the effectiveness of its Emergency Operations Plan.
• The hospital has a reliable emergency electrical power source.
• The hospital has an Emergency Operations Plan. Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This "all hazards" approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
• The hospital has an infection prevention and control plan.
• The hospital honors the patient's right to give or withhold informed consent.
• 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 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 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 makes food and nutrition products available to its patients.
• The hospital manages fire risks.
• 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 manages safety and security risks.
• 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 operating features that conform to fire and smoke prevention requirements.
• 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, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
• 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 medical record contains information that reflects the patient's care, treatment, and services.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
• Those who work in the hospital are focused on improving safety and quality.

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.