D.3 SPG 2026 Final Doc Review Tool.pdf

Copyright: 2026 Joint Commission Hospital Survey Process Guide - Compliance Evaluation Tools Page 522 of 709

Hospital Physical Environment Document List & Review Tool Revised - Effective: 4/20/2024

The following pages present documentation required by the Hospital Accreditation program Physical Environment (PE) standards. The Life Safety surveyor will begin review of these documents soon after arrival for the on-site survey. Surveyors may request other documents, as needed, throughout the survey. This list also includes some elements of performance that do not require documentation but appear as reminders to both organizations and surveyors of these expectations.

Please conduct during Facility Orientation.

Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

STANDARD -

EPs

See Legend Document / Requirement Yes No C NC NA IOU PE.03.01.01 Buildings serving patients comply w/ NFPA 101 (2012)

EP 1

Current and accurate drawings w/ fire safety features & related square footage

a. Areas of building fully sprinklered (if building only partially sprinklered)

b. Locations of all hazardous storage areas

c. Locations of all fire-rated barriers

d. Locations of all smoke-rated barriers

e. Sleeping and non-sleeping suite boundaries, including size of identified suites

f. Locations of designated smoke compartments

g. Locations of chutes and shafts

h. Any approved equivalencies or waivers

EP 5

The hospital maintains written evidence of regular inspection and approval by state or local fire control agencies.

EP 2 The hospital maintains current Basic Building Information (BBI) within the Statement of Conditions (SOC).

COMMENTS:

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 523 of 709

STANDARD -

EPs See Legend Document / Requirement Yes No

C NC NA IOU

PE.03.01.0

1 Hospital Manages Fire Risk – Fire Response Plan

EP 4

The hospital has written fire control plans that include provisions for prompt reporting of fires; extinguishing fires; protection of patients, staff, and guests; evacuation; and cooperation with firefighting authorities.

Staff periodically instructed on/kept informed of duties under plan

Copy of plan readily available with telephone operator or security

NFPA 101-2012: 18/19.7.1; 7.2

Please conduct after Facility Orientation, during Document Review activity.

STANDARD -

EPs

See Legend Document / Requirement Frequency Q1 Semi

Q2 Q3 Semi

Q4 AnnualC NC NA IOU

PE.04.01.01 Fire Protection and Suppression Testing and Inspection

EP 2

(Specific content addressed on K-tag

Tool)

Testing for pressure supervisory indicating devices (including both high- and low-air pressure switches), water level supervisory indicating devices, water temperature supervisory indicating devices, room temperature supervisory indicating devices, and other suppression system supervisory initiating devices NFPA 72-2010: Table 14.4.5

Quarterly

Testing for valve supervisory switches NFPA 72-2010: Table 14.4.5 Semiannual

Testing for other supervisory initiating devices NFPA 72-2010: Table 14.4.5

Annually

Water flow devices Semiannual

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STANDARD -

EPs

See Legend Document / Requirement Frequency Q1 Semi

Q2 Q3 Semi

Q4 AnnualC NC NA IOU

PE.04.01.01 Fire Protection and Suppression Testing and Inspection

EP 2 NFPA 72-2010: Table 14.4.5 NFPA 25-2011: Table 5.1.1.2 Tamper switches NFPA 72-2010: Table 14.4.5 Semiannual

EP 2

Duct, heat, smoke detectors, and manual fire alarm boxes NFPA 72-2010: Table 14.4.5; 17.14

Annually

EP 2

Notification devices (audible & visual), and door-releasing devices NFPA 72-2010: Table 14.4.5

Annually

EP 2

Emergency services notification transmission equipment NFPA 72-2010: Table 14.4.5

Annually

EP 2

Electric motor-driven fire pumps tested under no-flow conditions

NFPA 25-2011: 8.3.1; 8.3.2

Monthly

Diesel-engine-driven fire pumps tested under no-flow conditions

NFPA 25-2011: 8.3.1; 8.3.2

Weekly

EP 2

Sprinkler systems main drain tests on all risers NFPA 25-2011: 13.2.5; 13.3.3.4; Table 13.1.1.2; Table 13.8.1

Annually

EP 2

Fire department connections inspected (Fire hose connections N/A) NFPA 25-2011: 13.7; Table 13.1.1.2

Quarterly

EP 2

Fire pump(s) tested – under flow Fire pump supervisory signals for pump running and pump power loss tested

NFPA 25-2011: 8.3.3; 8.3.3.4

EP 2 Standpipe flow test every 5 years 5 years

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 525 of 709

STANDARD -

EPs

See Legend Document / Requirement Frequency Q1 Semi

Q2 Q3 Semi

Q4 AnnualC NC NA IOU

PE.04.01.01 Fire Protection and Suppression Testing and Inspection

NFPA 25-2011: 6.3.1; 6.3.2; Table 6.1.1.2

EP 2

Kitchen suppression semi-annual testing NFPA 96-2011: 11.2 Semiannual

EP 2

Carbon dioxide systems tested NFPA 12-2011:4.8.3.2 Annually

Halon systems NFPA 12A-2009: 6.1 Semiannual

Other special systems per National Fire Protection Association standards and manufacturers’ recommendations

NFPA 11-2010; NFPA 16-2011; NFPA 17-

2009; NFPA 17A-2009

EP 2

Portable fire extinguishers inspected monthly

NFPA 10-2010: 7.2.2; 7.2.4

Monthly

EP 2

Portable fire extinguishers maintained annually

NFPA 10-2010: 7.1.2; 7.2.2; 7.2.4; 7.3.1

Annually

EP 2

Fire hoses hydro tested 5 years after install; every 3 years thereafter NFPA 1962-2008: Chapter 7 and NFPA 25-2011: Chapter 6

5 years / 3 years

EP 2

Smoke and fire dampers tested to verify full closure

NFPA 90A-2012: 5.4.8; NFPA 80-2010:

19.4; NFPA 105-2010: 6.5

1 year after install

At least every 6 years thereafter

EP 2

Smoke detection shutdown devices for HVAC tested

NFPA 90A-2012: 6.4.1

Annually

EP 2

All horizontal and vertical roller and slider doors tested Annually

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 526 of 709

STANDARD -

EPs

See Legend Document / Requirement Frequency Q1 Semi

Q2 Q3 Semi

Q4 AnnualC NC NA IOU

PE.04.01.01 Fire Protection and Suppression Testing and Inspection

NFPA 80-2010: 5.2.14.3; NFPA 105-

2010: 5.2.1; 5.2.2

EP 2 (or

PE.03.01.01,

EP 3)

Inspection and testing of door assemblies by qualified person. Does not include nonrated doors, including corridor doors to patient care rooms and smoke barrier doors.

NFPA101-2012: 7.2.1.5.10.1; 7.2.1.5.11;

7.2.1.15; NFPA 80-2010: 4.8.4; 5.2.1;

5.2.3; 5.2.4; 5.2.6; 5.2.7; 6.3.1.7; NFPA

105-2010: 5.2.1

Annually

EP 2 (or

PE.03.01.01,

EP 3)

Elevators with firefighters’ emergency operations

NFPA 101-2012: 9.4.3; 9.4.6

Monthly

EP 1

Documentation of maintenance testing and inspection activities for EPs 1-3 includes: activity name; date; inventory of devices, equipment or other items;

frequency; contact info for person performing activity; NFPA standard; activity results

NFPA 25-2011: 4.3; 4.4; NFPA 72-2010:

14.2.1; 14.2.2; 14.2.3; 14.2.4

COMMENTS:

STANDARD -

EPs See Legend Document / Requirement Frequency Yes No / Missing Date

C NC NA IOU

PE.03.01.01

EP 3 and

PE.04.01.01

EP 1

Emergency Power Systems are Maintained and Tested

EP 3 or EP1 At least monthly performs functional test of emergency lighting systems and exit signs Monthly

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 527 of 709

STANDARD -

EPs See Legend Document / Requirement Frequency Yes No / Missing Date

C NC NA IOU

PE.03.01.01

EP 3 and

PE.04.01.01

EP 1

Emergency Power Systems are Maintained and Tested required for egress and task lighting for a minimum duration of 30 seconds, along with a visual inspection of other exit signs

NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-

2012: 6.3.2.2.11.5

EP 3 or EP1

Every 12 months performs functional test of battery powered lights on the inventory required for egress and exit signs for a duration of 1 ½ hours

For new construction, renovation, or modernization battery-powered lighting in locations where deep sedation and general anesthesia are administered is tested annually for 30 minutes with test results and completion dates documented

NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-

2012: 6.3.2.2.11.5

Annually

EP 3 or EP1

Functional test of Level 1 SEPSS, monthly;

Level 2 SEPSS, quarterly, for 5 minutes or as specified for its class Annual test at full load for 60% of full duration of its class

NFPA 111-2010: 8.4

Monthly Quarterly Annually

Note 1: Non-SEPSS tested per manufacturer’s specifications Per Mfr.

Note 2: Level 1 SEPSS defined for critical areas and equipment Note 3: Class defines minimum time which SEPSS is designed to operate at rated load without recharging

EP 3 or EP1

Emergency power supply system (EPSS) inspected weekly, including all associated components and batteries

NFPA 110-2010: 8.3.1; 8.3.3; 8.3.4; 8.4.1

Weekly

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STANDARD -

EPs See Legend Document / Requirement Frequency Yes No / Missing Date

C NC NA IOU

PE.03.01.01

EP 3 and

PE.04.01.01

EP 1

Emergency Power Systems are Maintained and Tested

EP 3 or EP1

Emergency generators tested monthly for 30 continuous minutes under load (plus cool-down)

NFPA 99-2012: 6.4.4.1

Monthly

EP 3 or EP1

Monthly load test for diesel-powered emergency generators conducted with dynamic load at least 30% of nameplate rating or meets mfr. recommended prime movers’ exhaust gas temperature; OR

Monthly

Emergency generators tested once every 12 months using supplemental loads of 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes for total of 1 ½ continuous hours

NFPA 99-2012: 6.4.4.1

Annually

EP 3 or EP1

All automatic and manual transfer switches monthly/12 times per year with results and completion dates documented

NFPA 99-2012: 6.4.4.1

Monthly

EP 3 or EP1 Fuel quality test to ASTM standards NFPA 110-2010: 8.3.8 Annually

EP 3 or EP1 Generator load test once every 36 months for 4 hours NFPA 110-2010, Chapter 8

36 Months

EP 3 or EP1 Generator 4-hour test performed at, at least 30% nameplate NFPA 110-2010, Chapter 8

36 Months

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 529 of 709

STANDARD -

EPs

See Legend Document / Requirement

THIS MAY BE SCORED AS

CONDITIONAL OR

STANDARD

Testing Dates

C NC NA IOU Yes No

PE.04.01.0

Medical Gas and Vacuum Systems are

Inspected and Tested

EP 3

Test, inspect and maintain critical components of piped medical gas and vacuum systems, waste anesthetic gas disposal (WAGD), and support gas systems on the inventory.

Inventory of critical components includes at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and inlets and outlets with activities, dates and results documented

No prescribed frequency; recommend risk assessment if < annual

NFPA 99-2012: 5.1.14.2; 5.1.15; 5.2.14;

5.3.13

Per policy

EPs 1, 3 Location of and signage for bulk oxygen systems

NFPA 99-2012: 5.1.3.5.12

On Bldg. Tour

EPs 1, 3 Emergency oxygen supply connection NFPA 99-2012: 5.1.3.5.13 On Bldg. Tour

EPs 1, 3

Review medical gas installation/modification/breech certification results for cross connection, purity, correct gas, and pressure

NFPA 99-2012: 5.1.2; 5.1.4; 5.1.14.4.1;

5.1.14.4.6; 5.2.13

As applicable

EP 1

Medical gas supply and zone valves are accessible and clearly labeled NFPA 99-2012: Table 5.1.11

NFPA 99-2012: 5.1.4; 5.1.11.1; 5.1.11.2;

5.1.14.3; 5.2.11; 5.3.13.3; 5.3.11

On Bldg. Tour

EP 1

Handling, transfer, storage, labeling, transfilling of cylinders

NFPA 99-2012: 11.5.3.1; 11.6.1; 11.6.2;

11.6.5; 11.7.3

Per policy

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 530 of 709

STANDARD -

EPs

See Legend Document / Requirement

THIS MAY BE SCORED AS

CONDITIONAL OR

STANDARD

Testing Dates

C NC NA IOU Yes No

PE.04.01.0

Medical Gas and Vacuum Systems are

Inspected and Tested

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Frequency Q1 Q2 Q3 Q4

AnnualC NC NA IOU

PE.03.01.0

1 Fire Drills

EP 3

Fire drills once per shift per quarter in health care occupancies; Quarterly in each building defined as ambulatory health care occupancy (If available, please provide five quarters of fire drill data)

NFPA 101-2012: 18/19: 7.1.7

Quarterly

EP 3 Fire drills every 12 months from date of last drill: Business Occupancies Annually

EP 3

When quarterly fire drills are required, ALL are unannounced

• Drills held at unexpected times and under varying conditions – at least one hour apart for each shift from quarter to quarter through four consecutive quarters

• Drills include transmission of fire alarm signal and simulation of emergency fire conditions

NFPA 101-2012: 18/19: 7.1.7; 7.1;

7.2; 7.3

Quarterly (See fire drill matrix)

PE.04.01.0

1 EP 1

Fire exit drills for operating rooms/surgical suites.

NFPA 99-2012: 15.13.3.10.3

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 531 of 709

STANDARD -

EPs

See Legend Document / Requirement Frequency Q1 Q2 Q3 Q4

AnnualC NC NA IOU

PE.03.01.0

1 Fire Drills

PE.04.01.0

1 EP 1

Annual emergency procedures and fire training drills for hyperbaric facilities that include recording of time to evacuate all persons from area, involves applicable staff, and focuses on prevention and simulated extinguishment and evacuation.

NFPA 99-2012: 14.2.4.5.4;

14.3.1.4.5 NFPA 99-2012: B.14.2 and B.14.3

Annually

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU Manages risks associated with utility systems

PE.03.01.0

1 EP 3 or

PE.04.01.0

1 EP 1

In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity.

(form of and frequency of assessment per hospital policy)

Note: For more information about areas designed for control of airborne contaminants, the basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design (if available).

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 532 of 709

STANDARD -

EPs

See Legend Document / Requirement Yes No C NC NA IOU

PE.04.01.0

Manages risks associated with utility systems

– Water Management Program

EP 1 Verify individual or team responsible for oversight and implementation of the water management program

EP 2

Review water management program to verify the following components are included:

• Diagram of water supply sources, treatment systems, processing steps, control measures, and end-use points

• Water risk management plan identifies areas where potentially hazardous conditions may occur o Note: Refer to the Centers for Disease Control and

Prevention’s “Water Infection Control Risk Assessment (WICRA) for Healthcare Settings” tool as an example for conducting a water-related risk assessment.

• Plan for addressing the use of water in areas of buildings where water may have been stagnant for a period of time

• Evaluation of immunocompromised patients

• Monitoring protocols and acceptable ranges for control measures

EP 3

Verify that the water management program includes documentation of the following:

• Results of all monitoring activities

• Corrective actions and procedures to follow if test results are outside of acceptable limits

• Corrective actions taken when control limits are not maintained

EP 4

Verify water management program reviewed annually and when changes have been made to the water system that add risk, new equipment or at-risk systems have been added that could generate aerosols or be source for Legionella

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Yes No C NC NA IOU

PE.04.01.0

1 Management of Medical Equipment Risks

EP 2 Non-deemed status requirement: Maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 533 of 709

STANDARD -

EPs

See Legend Document / Requirement Yes No C NC NA IOU

PE.04.01.0

1 Management of Medical Equipment Risks by physical risk associated with use (including all life-support equipment) and equipment incident history.

Evaluates new types of equipment before initial use to determine whether they should be included in the inventory.

OR

Deemed status requirement: Maintains a written inventory of all medical equipment.

EP 2 High-risk medical equipment identified on the inventory

EP 2

Inventory includes activities and associated frequencies for maintaining, inspecting, and testing all medical equipment on the inventory.

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

PE.04.01.0

1 Medical equipment inspection, testing and maintenance

EP 2

All high-risk equipment.

Note 1: High-risk equipment includes medical equipment for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining, inspecting, and testing of medical equipment must have a 100% completion rate.

EP 2

Non-high-risk equipment identified on the medical equipment inventory

EP 2

Conducts performance testing of and maintains all sterilizers

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 534 of 709

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

PE.04.01.0

1 Medical equipment inspection, testing and maintenance

EP 1, 2

All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99- 2012: Chapter 14.

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

PE.04.01.0

1 Utility system Inspection, testing and maintenance

EP 2

High-risk utility system components on the inventory with completion date and results of activities documented

Note 1: A high-risk utility system includes components for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components must have a 100% completion rate.

EP 2

Infection control utility system components on the inventory with completion date and results of activities documented

Note 1: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components must have a 100% completion rate.

EP2

Non-high-risk utility system components on the inventory with completion date and results of activities documented

EP 2

Line isolation monitors (LIM), if installed, are tested at least monthly by actuating the LIM test switch. For LIM circuits with automated self-testing, a manual test is performance at least annually.

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 535 of 709

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

PE.04.01.0

1 Utility system Inspection, testing and maintenance

NFPA 99-2012: 6.3.2; 6.3.3; 6.3.3.3.2; 6.3.4

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

NPG.11.01.0

NPG.02.04.0

The hospital manages security risks.

EP 2 The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric abduction.

EP 3

The hospital conducts an annual worksite analysis related to its workplace violence prevention program. The hospital takes actions to mitigate or resolve the workplace violence safety and security risks based upon findings from the analysis.

Note: A worksite analysis includes a proactive analysis of the worksite, an investigation of the hospital’s workplace violence incidents, and an analysis of how the program’s policies and procedures, training, education, and environmental design reflect best practices and conform to applicable laws and regulations.

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 536 of 709

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

NPG.11.01.

01 The hospital collects information to monitor conditions in the environment.

EP 3

EP 1 The hospital develops and implements processes for monitoring, internally reporting, and investigating the following:

- Injuries to patients or others within the hospital’s facilities

- Occupational illnesses and staff injuries

- Incidents of damage to its property or the property of others

- Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence

- Hazardous materials and waste spills and exposures

- Fire safety management problems, deficiencies, and failures

- Medical or laboratory equipment management problems, failures, and use errors

- Utility systems management problems, failures, or use errors

STANDARD -

EPs

See Legend Document / Requirement Addressed in policy? Implemented as required?

C NC NA IOU Yes No Yes No

PE.03.02.0

1 Interim Life Safety Measures (ILSM)

EP 1 ILSM policy identifying when and to what extent ILSM implemented

PE.03.01.0

1 EP 8 and

PE.03.02.0

1EP 2

Alarms out of service 4 or more hours in 24 hours or sprinklers out of service more than 10 hours in 24 hours in an occupied building - Fire watch / Fire Dept. notification

NFPA 101-2012: 9.6.1.6; 9.7.6; NFPA 25-

2011: 15.5.2

EP 3 Signs for alternate exits posted

EP 4 Daily inspection of routes of egress (See also

19.7.9.2 RE: daily inspections)

EP 5 Temporary but equivalent systems while system is impaired

EP 6 Additional firefighting equipment provided

EP 7 Smoke tight non-combustible temporary barriers

EP 8 Increased surveillance implemented

EP 9 Storage and debris removal

Copyright: 2026 Joint Commission Hospital Accreditation Survey Process Guide Page 537 of 709

STANDARD -

EPs

See Legend Document / Requirement Addressed in policy? Implemented as required?

C NC NA IOU Yes No Yes No

PE.03.02.0

1 Interim Life Safety Measures (ILSM)

EP 10 Additional training on firefighting equipment

EP 11 Additional fire drill per shift per quarter

EP 12 Temporary systems tested and inspected monthly

EP 13 Additional training on building deficiencies, construction hazards, temp measures

EP 14 Training for impaired structural or impaired compartment fire safety features

EP 15 Other ILSM's

COMMENTS:

NOTE: Please complete the following during building tour

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

PE.02.01.0

1 The hospital manages risks related to hazardous materials and waste.

EP 1

The hospital maintains a written, current inventory of hazardous materials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those whose handling, use, and storage are addressed by law and regulation. (See also IC.02.01.01, EP 6;

MM.01.01.03, EPs 1 and 2)

EP 4

The hospital has written procedures, including the use of precautions and personal protective equipment, to follow in response to hazardous material and waste spills or exposures.

EP 2

For managing hazardous materials and waste, the hospital has the permits, licenses, manifests, and safety data sheets required by law and regulation.