Background:

In 2026, the Joint Commission modified their approach to evaluating the Physical Environment for the Hospital Accreditation Program (HAP) and the Critical Access Hospital (CAH) program. Their goal was to align the HAP and CAH programs with CMS Conditions of Participation (COP) requirements. The Joint Commission referred to requirements found in the CMS State Operations Manual (SOM) Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals A-Tags into this project. 

These A-Tags are written at a high level. In the 2026 Physical Environment (PE) chapter, the Elements of Performance are more of a summary statement, requiring the accredited organization to have previous knowledge of the requirements. Fortunately, the Joint Commission has provided worksheets that provide this information. These worksheets are the same that the Life Safety Code Surveyor (LSCS) will use during the survey. The previous Environment of Care (EC) and Life Safety (LS) Chapters provided detailed Elements of Performance to achieve compliance, originally created by George Mills, using the CMS COPs. Because of this, if your program was compliant in 2025, it should still be compliant going forward. The major issue will be demonstrating compliance with the PE chapter requirements, evidenced by your previous program documentation.   

An example of the PE language and the CMS requirements is found in CMS A-0710 and Joint Commission .03.01.01, EP 3. The wording and intent are essentially the same: both state that we are to comply with the 2012 NFPA Life Safety Code®, including some Tentative Interim Amendments (TIA) as listed in the A-Tag and EP.  

CMS: 

§482.41(b) Standard: Life safety from fire. 

The hospital must ensure that the life safety from fire requirements are met. 

[A-0710]

1. Except as otherwise provided in this section—  
2. The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care (AHC) Occupancies, regardless of the number of patients served.

‍

Joint Commission: 

Standard PE.03.01.01 The hospital designs and manages the physical environment to comply with the Life Safety Code.   

EP 3 The hospital meets the applicable provisions of the Life Safety Code (NFPA 101-2012 and Tentative Interim Amendments [TIA] 12-1, 12-2, 12-3, and 12-4). 

• Note 1: Outpatient surgical departments meet the provisions applicable to ambulatory health care occupancies, regardless of the number of patients served.

‍

Joint Commission & Business Occupancies

What is important to note is that these changes currently apply to the Joint Commission Hospital Accreditation Program (HAP) and Critical Access Hospitals (CAH). Within both programs are Business Occupancies, which are also referred to as Outpatient Facilities. At the beginning of 2026, the Joint Commission announced that there is an increase in the survey process for Life Safety Code compliance in Outpatient Facilities. When surveying these Outpatient Facilities, the Life Safety Code Surveyor (LSCS) will coordinate with the Clinical Surveyors and determine which off sites to survey. Additional survey days may be added to accommodate these extra survey activities. 

Outpatient Facilities include Intensive Chemotherapy; Complex Wound Care; Advanced Cardiac Rehab and Intensive Medication Management. The previous locations that were added in 2020 (Ambulatory Surgical Center and Free-Standing Emergency Departments) will continue to be surveyed as well. The LSCS will review Inspection, Testing and Maintenance documentation; the Life Safety Code drawings; SOC/BBI Documentation and conduct above ceiling inspections.   

Currently, the Joint Commission has not revised the business occupancy requirements for Life Safety Code Compliance. The survey process will continue to use the LS.05.xx.xx standards. If the survey is for a HAP or CAH that includes business occupancies, the Life Safety Code Surveyor will go to the intended site and survey. Documentation of any Requirements for Improvement (RFI) will be by using the LS Chapter for Business Occupancies (LS.05.xx.xx) for survey scoring. Applicable codes include the 2012 Life Safety Code, chapters 38/39 and NFPA 99-2012 (which is not occupancy dependent). Although the LS chapter has not been modified for the business occupancies, the current LS.05.xx.xx standards are based on the CMS requirements, so complying with CMS is still seamless.   

If the survey includes an Ambulatory Surgical Center, there are additional requirements if receiving CMS funding. For example, the occupancy type is always Ambulatory, regardless of how many patients are rendered incapable of self-preservation. Although the Life Safety Code allows up to three patients to be rendered incapable of self-preservation and be defined as a Business Occupancies, CMS has clarified in their A-Tag above that this does not apply. The Joint Commission added this same language into their PE.03.01.01 EP 3 language. Both would require compliance with the NFPA Life Safety Code 101-2012 chapters 20/21 and NFPA 99-2012. 

Two resources are available from CMS. When CMS conducts a survey, they use either the CMS-2786R (Healthcare) or CMS-2786U (Ambulatory Health Care) forms. The K-Tags are found in these forms. For the Hospital program, the A-Tag A-0702 cites “Survey Procedures §482.41(a)(1). Use the Life Safety Code Survey Report Form (CMS-2786) to evaluate compliance with this item.” These K-Tags are the foundation requirements of CMS for all states that evaluate for CMS, and the accrediting organizations, including Joint Commission, DNV, ACHA and others. 

  Healthcare K-Tags, Form CMS-2786R (rev. 07/20158): 

• The Healthcare K-Tag form is the form CMS uses to evaluate NFPA 101-2012, Life Safety Code (LSC) and NFPA 99-2012 (Health Care Facilities) compliance. Also included are requirements in the NFPA codes referenced in chapter two (Referenced Publications) of the LSC and NFPA 99.    
• https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2786R.pdf
  
  

Ambulatory K-Tags, Form CMS-2786U (rev. 07/2018):

• The Ambulatory Health Care K-Tag form is the form CMS uses to evaluate NFPA 101-2012, Life Safety Code (LSC) and NFPA 99-2012 (Health Care Facilities) compliance. Also included are requirements in the NFPA codes referenced in chapter two (Referenced Publications) of the LSC and NFPA 99.   
• https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS2786U.pdf 

‍

NOTE 1: If the survey is for the Ambulatory Health Care accreditation program, the move to the new Physical Environment Chapter does not apply at this time. The surveyor will continue to review the Environment of Care and Life Safety Chapters as in the past.  

NOTE 2: Hospice: Freestanding and Hospital-based - The Life Safety Code Surveyor will also survey these locations. One day will be allocated for each freestanding inpatient location (time for the LSCS at Hospital-based Hospice has already been part of the survey team).

‍