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.

• 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.
• 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.
• Medication orders are clear and accurate.
• Resuscitation 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 reassesses its patients.
• The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
• The hospital conducts fire drills.
• The hospital designs and manages the physical environment to comply with the Life Safety Code.
• The hospital effectively manages the collection of health information.
• 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 an infection prevention and control plan.
• The hospital honors the patient's right to give or withhold informed consent.
• The hospital identifies risks for acquiring and transmitting infections.
• 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 the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital 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 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 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 systems for extinguishing fires.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• The hospital provides patient education and training based on each patient’s needs and abilities.
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital safely prepares medications.
• The hospital safely stores medications.
• The hospital verifies staff qualifications.