42 CFR §456.243

1. (a)Identify and analyze medical or administrative factors related to the mental hospital's patient care;
2. (b)Include analysis of at least the following:
   1. (1)Admissions.
   2. (2)Durations of stay.
   3. (3)Ancillary services furnished, including drugs and biologicals.
   4. (4)Professional services performed in the hospital; and
3. (c)If indicated, contain recommendations for change beneficial to patients, staff, the hospital, and the community.