The Joint Commission Physical Environment Standards

Recently, The Joint Commission announced a major shift in philosophy with the creation of Accreditation 360: The New Standard. This update has been designed to enhance the accreditation experience and reduce administrative burden by streamlining requirements to clearly align them with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs). These changes will be effective January 1, 2026 and are marking a major restructuring of its standards which will result in removing over 700 hundred legacy standards. The restructuring includes retiring the Environment of Care and Life Safety chapters and replacing them with The Physical Environment Standards. While the changes are significant, they introduce no new concepts.

While The Physical Environment Module and Accreditation 360 provide a vast array of administrative changes, the standards have also, undergone some changes in the way that they are presented. The addition by subtraction approach has created quite a few broad Elements of Performance within The Physical Environment standards. With a minimal number of EPs, the Physical Environment Module tends defer to NFPA and The CMS Conditions of Participation rather than listing every requirement line by line. It would appear that The Joint Commission is relying on your universal understanding of these Codes and Standards to create a safe environment for your patients, staff, and visitors. 

It depends. Because The Physical Environment Standards rely heavily on the CMS Conditions of Participation your understanding of codes such as NFPA 101 - Life Safety Code and NFPA 99 -  Health Care Facilities Code is pivotal. If you are already performing your inspections, testing and maintenance according to these (and other) standards then there should be no cause for alarm. If you do not have a good grasp of the various requirements, tables, and frequencies then The Physical Environment and  Standards could trip you up because The Joint Commission is not itemizing every requirement in the new Accreditation 360 process. 

It is important to note that none of the NFPA Codes or CMS K-Tags have changed which means that none of the requirements have either.

Accreditation 360 does not make specific mention of having a no smoking policy in any of the new Physical Environment EPs. With that being said, it is in the Life Safety Code and is a CMS Conditions of Participation requirement listed and scored under the K-tag K741. The Joint Commission will score this under The Physical Environment Module within PE.03.01.01, EP3 and PE.04.01.01 EP1. Neither of these EPs discuss the mandatory requirements for a no smoking policy in your hospital but do reference the applicability of NFPA 101 and NFPA 99.

The documentation requirements for the inspection, testing, and maintenance of fire alarm, and suppression systems, etc. have not changed but instead of them being spread out in 20-some EPs in EC.02.03.05, they can now be found condensed under one heading - PE.04.01.01, EP2. Similarly, where Emergency Power documents were itemized in multiple EPs in section EC.02.05.07, they are now scored in either PE.03.01.01 EP 3 or PE.04.01.01 EP 1 .

The bottom line here is that very little has changed for you and your organization as patient safety is still the primary goal regardless of what it is called. Yes, Accreditation 360 changed the names and layout, but the requirements have not changed. Codes such as NFPA 101 and NFPA 99 have always been an integral part of TJC standards & the CMS Conditions of Participation and have always been enforceable. Despite being written up a little bit differently in The Physical Environment Module has not changed these facts. You are still responsible for the same policies and procedures, fire stopping, airflow, ITM, temperature, and general repair of your building(s) that you always have been.

Accreditation 360 does not make specific mention of having a no smoking policy in any of the new Physical Environment EPs. With that being said, it is in the Life Safety Code and is a CMS Conditions of Participation requirement listed and scored under the K-tag K741. The Joint Commission will score this under The Physical Environment Module within PE.03.01.01, EP3 and PE.04.01.01 EP1. Neither of these EPs discuss the mandatory requirements for a no smoking policy in your hospital but do reference the applicability of NFPA 101 and NFPA 99.

The documentation requirements for the inspection, testing, and maintenance of fire alarm, and suppression systems, etc. have not changed but instead of them being spread out in 20-some EPs in EC.02.03.05, they can now be found condensed under one heading - PE.04.01.01, EP2. Similarly, where Emergency Power documents were itemized in multiple EPs in section EC.02.05.07, they are now scored in either PE.03.01.01 EP 3 or PE.04.01.01 EP 1 .

The Mock Surveys provided by AjudaHC are always the best way to gauge your readiness for a live survey under the Accreditation 360 or EOC program. This is especially true now that the Physical Environment standards are so broad and no longer itemize various standards in unique EPs. Regardless if it is called, The Environment of Care or The Physical Environment, we are always digging deeper to provide the safest possible facility your patients. Our surveys and consulting services can help guide you through The Physical Environment changes, your next survey, and beyond.

Please contact us with any questions about these changes, mock surveys, or consulting services.