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 individuals at risk for suicide.
• The organization assesses the outcomes of care, treatment, or services provided to the individual served.
• The organization manages fire risks.
• 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.
• Documentation in the medical record is entered in a timely manner.
• 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.
• Medical staff bylaws address self-governance and accountability to the governing body.
• Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
• Report critical results of tests and diagnostic procedures on a timely basis.
• 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 assesses and reassesses the patient and his or her condition according to defined time frames.
• The hospital collects data to monitor its performance.
• The hospital compiles and analyzes data.
• 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 an organizationwide, integrated patient safety program within its performance improvement activities.
• The hospital has policies and procedures that guide and support patient care, treatment, and services.
• The hospital implements its infection prevention and control plan.
• 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 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 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, 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 reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This right is not to be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.
• The hospital respects the patient's right to receive information in a manner he or she understands.
• The hospital traces all tissues bi-directionally.
• The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
• The medical record contains information that reflects the patient's care, treatment, and services.
• The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.
• The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

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.
• Identify individuals at risk for suicide.
• The organization assesses the outcomes of care, treatment, or services provided to the individual served.
• The organization manages fire risks.
• 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.
• Documentation in the medical record is entered in a timely manner.
• 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.
• Medical staff bylaws address self-governance and accountability to the governing body.
• Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
• Report critical results of tests and diagnostic procedures on a timely basis.
• 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 assesses and reassesses the patient and his or her condition according to defined time frames.
• The hospital collects data to monitor its performance.
• The hospital compiles and analyzes data.
• 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 an organizationwide, integrated patient safety program within its performance improvement activities.
• The hospital has policies and procedures that guide and support patient care, treatment, and services.
• The hospital implements its infection prevention and control plan.
• 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 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 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, 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 reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This right is not to be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.
• The hospital respects the patient's right to receive information in a manner he or she understands.
• The hospital traces all tissues bi-directionally.
• The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
• The medical record contains information that reflects the patient's care, treatment, and services.
• The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.
• The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
• The patient’s medical record documents operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.