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 pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
• A time-out is performed before the procedure.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Hospital leaders allocate needed resources for the infection prevention and control program.
• Policies and procedures for waived tests are established, current, approved, and readily available.
• 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.
• Report critical results of tests and diagnostic procedures on a timely basis.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.
• The hospital assesses and reassesses the patient and the patient's condition according to defined time frames.
• The hospital defines and verifies staff qualifications.
• 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 has an organizationwide, integrated patient safety program within its performance improvement activities.
• 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 medical equipment.
• 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.
• The hospital makes food and nutrition products available to its patients.
• 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 manages safety and security risks.
• 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.
• The hospital provides and maintains fire alarm systems.
• 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 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 stores medications.
• 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.