Are Joint Commission environment of care management plans still required?

Jan. 1, 2026, marked a day of significant change in how Joint Commission (JC) treats its physical environment standards for hospitals and critical access hospitals (CAH). In 2025, JC announced that it would retire the Environment of Care and Life Safety chapters from its Hospital and Critical Access Hospital accreditation manuals, consolidating them into one new Physical Environment Chapter. The accrediting organization made the change in effort to better align with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.

But while the formatting of its standards would change, JC made it clear that the requirements themselves would not and that hospitals and CAHs should not make changes to their existing programs since they are still held to CMS’s requirements.

While many standards and associated elements of performance (EPs) can still be found in the updated manuals, many standard numbers have changed, and several existing EPs have been relocated to the newly created National Performance Goals. Also, several requirements are now generalized under the EPs that state hospitals must meet the National Fire Protection Association’s 2012 editions of NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code.

A change in environment of care management plans

There is one question and overarching concern, however, that remains consistent from health care organizations in the field: Are environment of care management plans for the following programs still required by JC?

• Safety management
• Security management
• Hazardous materials and waste management
• Fire safety management
• Medical equipment management
• Utility systems management

In its January 2026 issue of Environment of Care News, JC stated that hospitals and CAHs are no longer required to have environment of care management plans for each of the above-listed physical environment areas. The newsletter stated that “except for ambulatory care organizations, Joint Commission no longer requires a written management plan or separate plans addressing each of the physical environment functional areas: safety, security, hazardous materials and waste, utilities, and medical equipment.”  JC further clarified that the only management plans that will be evaluated during a survey will be the organization’s fire response plan, water management plan and emergency operations plan.

Does this mean that hospitals and CAHs should get rid of their previously required environment of care management plans and annual evaluation process previously required by JC simply because surveyors will no longer ask for them? The simple answer is, “No.”

For years, the environment of care management plans have been utilized by organizations as the framework and roadmap for their respective plans and programs. These plans are used to summarize organizational processes such as:

• Committee names/processes. What is the committee officially titled, and what departments/leaders participate in the committee?
• Ownership of programs. Identify by title who is responsible for the ownership of the respective program, as well as the associated management plan and review process.
• Processes for continual compliance and ongoing monitoring. What is the rounding process for the organization? Who participates? What are the rounds, tours or tracers called by the organization?
• Staff education in the physical environment. What do staff need to know respective to the physical environment to ensure a safe workplace day to day? 

The core of management plans is the ability to summarize each respective program, including all the required aspects of that specific plan or program and, even more specifically, how each EP is addressed.

The purpose of the management plans has always been twofold:

1. Historically, the plans were required by JC as five separate elements under the old Environment of Care Chapter’s Planning Standard (EC.01.01.01). Each element had a requirement for documentation signified by a letter “D” in a circle at the beginning of the respective elements.
2. More importantly, the management plans are used by organizations to not only provide a roadmap to all of the required aspects of the standards for each respective plan but also to ensure that any supporting policies or procedures also are incorporated into the program — whether it’s an internal policy or procedure or a requirement of the accreditation process.

The argument to keep environment of care management plans in place

This is not the first time that JC has removed requirements from its standards with the expectation that organizations continue to execute management plans and processes. 

Some may remember a time when JC required accredited hospitals to conduct environmental tours every six months in patient care areas and annually in non-patient care areas. That requirement was deleted from the standards years ago, and the rationale behind the deletion of these requirements from the Environment of Care Chapter was simple: It is inherent that organizations conduct these processes through routine operations and will continue to do so without the strict prescription from JC.

Moving forward, organizations would benefit by continuing their management plans and evaluation processes, as this can be paramount in ensuring all program aspects are met for a safe environment day to day, regardless of what documentation a surveyor may ask to see at the time of survey.

While the requirement for environment of care management plans is not contained in JC’s new Physical Environment Chapter for hospitals and CAHs, the foundation of organizational compliance within the physical environment is still required, and continuing the process of evaluating and updating these management plans provides a path to help ensure continuous compliance.

Matthew Daniel, CHSP, is a senior consultant at Daniel Consulting LTD. He can be reached at matthew.daniel@danielconsulting.net.