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 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.
• 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 maintains the integrity of the means of egress.
• The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
• Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
• 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.
• 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.
• Medication orders are clear and accurate.
• Staff participate in ongoing education and training.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital addresses patient decisions about care, treatment, and services received at the end of life.
• The hospital assesses and manages the patient's pain.
• The hospital collects data to monitor its performance.
• The hospital documents the use of restraint or seclusion.
• 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 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 implements its infection prevention and control plan.
• 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 maintains complete and accurate medical records for each individual patient.
• 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 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 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 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 stores medications.
• The patient and his or her family have the right to have complaints reviewed by the hospital.

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.

• Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
• 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.
• 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.
• Medication orders are clear and accurate.
• Staff participate in ongoing education and training.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital addresses patient decisions about care, treatment, and services received at the end of life.
• The hospital assesses and manages the patient's pain.
• The hospital collects data to monitor its performance.
• The hospital documents the use of restraint or seclusion.
• 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 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 implements its infection prevention and control plan.
• 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 maintains complete and accurate medical records for each individual patient.
• 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 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 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 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 stores medications.
• The patient and his or her family have the right to have complaints reviewed by the hospital.