Source: Joint Commission, Accreditation 360 webinar, “Updated Accreditation Manual: Physical Environment Chapter” (transcript and slides, September 2025), slides 29–34, hospital program, data from May 1, 2024 to May 31, 2025. Joint Commission reports these as numbers of documented “opportunities” (findings), not as the share of surveys. It published the EC and LS lists as two separate top-five charts; this guide combines them into one list of ten ranked by count, which is an EHS Concepts presentation. * EHS Concepts calculation (sum of the ten published counts). The webinar does not say how many surveys these counts came from.
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Interior spaces not safe and suitable
- 865 documented findings, the No. 1 EC finding for hospitals
- PE.01.01.01 new location since Jan. 1, 2026 (EP 1 and EP 2)
- 5th of five physical environment areas in Joint Commission's June 2026 behavioral health ranking
Start here: Walk one unit with the charge nurse and a maintenance tech. Fix or ticket every damaged surface before you leave.
Rules and guidance: PE.01.01.01 EP 1, EP 2 (formerly EC.02.06.01 EP 1) [JC]; 42 CFR 482.41(a) [CMS]; 29 CFR 1910.37 [GI]
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Utility system controls not labeled
- 785 documented findings, the No. 2 EC finding for hospitals
- No. 1 for critical access hospitals (51 findings) and in the June 2026 behavioral health ranking
- Main shutoffs (gas, water, electrical) must be identifiable in an emergency
Start here: Open five panels this week. Turn off or label every “spare” breaker that is on, and print a new directory for each.
Rules and guidance: PE.04.01.01 EP 1 (formerly EC.02.05.01 EP 9) [JC]; 42 CFR 482.41(c) [CMS/NFPA]; 29 CFR 1910.303(f), (g) [GI]
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Sprinkler piping used to support other items
- 711 documented findings, the No. 1 LS finding for hospitals
- Above the ceiling is where surveyors find most of it: cables, conduit, and wire tied to sprinkler pipe
- EP 3 all top LS findings now score at PE.03.01.01 EP 3
Start here: Lift one tile every 20 feet down one corridor this week. Cut and re-support anything tied to sprinkler pipe.
Rules and guidance: PE.03.01.01 EP 3 (formerly LS.02.01.35 EP 4) [JC]; Life Safety Code and NFPA 13/25 via CMS K-tags [NFPA]; 42 CFR 482.41(b) [CMS]
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Non-high-risk utility and essential equipment not tested
- 684 documented findings, the No. 3 EC finding for hospitals
- 42 findings for critical access hospitals, No. 2 on their list
- EP 2 “maintains essential equipment in safe operating condition”
Start here: Pull last month's closed PMs for one system. Reopen any closed with no readings or notes.
Rules and guidance: PE.04.01.01 EP 2 (formerly EC.02.05.05 EP 6) [JC]; 42 CFR 482.41(d)(2) [CMS]; NFPA 99-2012 via K-tags [NFPA]
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Sprinkler installation and clearance problems
- 636 documented findings, the No. 2 LS finding for hospitals
- 18 in clear space below sprinkler deflectors that surveyors check in storage areas
- K351 CMS K-tag: sprinklers installed per NFPA 13
Start here: Mark the 18-inch line in your five fullest storage rooms this week and clear everything above it.
Rules and guidance: PE.03.01.01 EP 3 (formerly LS.02.01.35 EP 14) [JC]; NFPA 13-2010 via K351 [NFPA]; 42 CFR 482.41(b) [CMS]
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Environment not clean, odors present
- 615 documented findings, the No. 4 EC finding for hospitals
- PE.01.01.01 EP 3 since Jan. 1, 2026
- Dust on high surfaces, soiled floors, and odors are what surveyors note
Start here: Walk the back rooms on one unit with EVS and facilities together. Assign each dirty spot or odor to one of them.
Rules and guidance: PE.01.01.01 EP 3 (formerly EC.02.06.01 EP 20) [JC]; 42 CFR 482.41(a) [CMS]; 29 CFR 1910.1030(d)(4) [GI]
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Hazardous chemicals not handled and stored safely
- 611 documented findings, the No. 5 EC finding for hospitals
- 10 sec eyewash reach that Joint Commission's tracer tool asks about (about 55 feet)
- 33 findings for critical access hospitals, No. 3 on their list
Start here: Walk every janitor closet and soiled utility room this week. Label or remove every unlabeled container and test every eyewash.
Rules and guidance: PE.02.01.01 EP 4 (formerly EC.02.02.01 EP 5) [JC]; 29 CFR 1910.1200, 1910.151(c) [GI]
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Fire barrier penetrations not sealed
- 590 documented findings, the No. 3 LS finding for hospitals
- Above the ceiling and in electrical closets are where surveyors check for unsealed penetrations
- Every new cable or pipe through a rated wall is a new chance for a hole
Start here: Check every electrical and IT closet this week. Seal any open penetration with the listed system for that wall.
Rules and guidance: PE.03.01.01 EP 3 (formerly LS.02.01.10 EP 14) [JC]; Life Safety Code via K-tags [NFPA]; 42 CFR 482.41(b) [CMS]
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Sprinkler systems not maintained
- 570 documented findings, the No. 4 LS finding for hospitals
- NFPA 25 the inspection, testing, and maintenance standard surveyors use
- 6 months test interval for vane- and pressure-type waterflow devices
Start here: Pull your last sprinkler inspection report. Make sure every deficiency has a work order and a date.
Rules and guidance: PE.03.01.01 EP 3 (formerly LS.02.01.35 EP 5) [JC]; PE.04.01.01 EP 2; NFPA 25-2011 via K353 [NFPA]; 42 CFR 482.41(d)(2) [CMS]
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Fire-rated doors that do not meet requirements
- 568 documented findings, the No. 5 LS finding for hospitals
- Annual inspection and testing of fire door assemblies per NFPA 80, with written records
- Self-close doors may be held open only by a release device that closes them on alarm
Start here: Walk one floor this week. Pull every wedge, close every rated door, and check that it latches. Ticket every one that does not.
Rules and guidance: PE.03.01.01 EP 3 (formerly LS.02.01.10 EP 11) [JC]; PE.04.01.01 EP 2; NFPA 80-2010 via K761, K223 [NFPA]; 29 CFR 1910.37 [GI]
The full PDF adds, for each item, why it really happens, the rules in plain words, controls in hierarchy order, a 30-minute self-audit, who owns it and a toolbox talk starter.