Patton Post – October 2026

October 2026

Inside This Issue

October is usually the time of year when we start hearing about new accreditation requirements, rewritten standards, and changes that organizations will need to implement in January. After the major Joint Commission standards rewrite that took effect January 1, 2026, we are pleased to report that, so far, no additional major standards rewrite, new chapter, or new set of standards have been announced for January 2027.

That doesn’t mean there is nothing new to review. Joint Commission has made some significant organizational changes and edits to its Survey Process Guides and survey tools. These deserve attention, particularly for hospitals, critical access hospitals, and ambulatory surgery centers. We also highlight several useful Environment of Care resources, CMS updates, and some practical guidance from ACHC.

Survey Process Guides and Survey Tools Updates
If you haven’t looked at the September 2026 Survey Process Guides (SPGs), now would be a good time to do so.

Joint Commission has reorganized several of its survey guides, effective September 1, 2026. For hospitals and critical access hospitals, the former Survey Process Guide has been divided into two documents: the Survey Process Guide and a separate Survey Tools Guide.

This is more than simply moving pages from one document to another. The revised SPG includes an updated Document List and Discharge Planning evaluation model. The companion Survey Tools Guide contains several revised tools, including the Kitchen Tracer, Document Review, Building Tour, and Ambulatory and Business Occupancy Building Tour tools.

Two new tools have also been added: a Construction Survey tool and a Hyperbaric Tour tool.

For ambulatory surgery centers, the revised Survey Activity Guide adds 42 CFR §416.42, Surgical Services, to individual tracer activities for deemed status surveys.

The laboratory guide also clarifies that manufacturers’ recommendations and suggestions are no longer surveyed as requirements.

Each guide includes a Summary of Changes, which is a useful place to start.

Field Impact — What We Recommend Reviewing
We recommend that Accreditation leaders download the revised guides for their programs rather than relying on older versions. Start with the Summary of Changes, but don’t stop there.

For hospitals, pay particular attention to the revised Document List and Discharge Planning evaluation model. Facilities and Life Safety leaders should review the building tour and document review tools. If you have construction underway or operate hyperbaric services, be sure to review those new tools.

ASC leaders should review the addition of the Surgical Services Conditions for Coverage to individual tracers.

Leadership Changes for 2027 Announcement
There will also be a change in leadership at Joint Commission next year.

Jonathan Perlin, MD, PhD, will retire as president and CEO on December 31, 2026. James Merlino, MD, currently Joint Commission’s chief operating officer, will assume the role on January 1, 2027.

Joint Commission has indicated that its current strategic priorities will continue under the new leadership.

Field Impact
There is nothing organizations need to do in response to this announcement. However, we will be watching for any changes in direction involving accreditation requirements, survey processes, and performance measurement as the new leadership team takes over.

DMEPOS Accreditation Changes May Affect Health System Programs
This is a more specialized announcement, but one that could be important for health systems operating durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services.

Effective October 1, 2026, organizations using Joint Commission DMEPOS accreditation for Medicare enrollment must transition to a standalone DMEPOS accreditation program.

The change does not apply to suppliers that do not use Joint Commission accreditation for Medicare enrollment.

Field Impact
If your health system operates DMEPOS services, we recommend confirming whether any of those locations rely on Joint Commission accreditation for Medicare enrollment. If they do, make sure the appropriate staff are aware of the transition requirements.

UNIFY 2026: What Did Joint Commission Say About Patient Safety and AI?
Joint Commission held its UNIFY 2026 conference in Washington, DC this September.

Presentations focused on the potential for AI to play a larger role in preventing patient harm, AI governance, nursing, pediatric care, empathy-driven care, and approaches to quality improvement across health systems.

While these discussions did not introduce new accreditation requirements, they offer some insight into topics receiving attention at Joint Commission.

Field Impact — Is Your Organization Addressing AI Governance?
Many organizations are already using AI in clinical and operational processes. We recommend that Accreditation, Regulatory, Quality, and Patient Safety leaders be involved in those discussions.

Consider whether your organization has a process for reviewing the safety implications of AI applications, monitoring their performance, and identifying who is responsible when problems occur.

AI governance should not be left entirely to Information Technology.

A Closer Look at the Revised Survey Tools
We mentioned the revised Survey Process Guides earlier, but the October EC News provides some additional information that Facilities and Life Safety leaders will want to review.

Several Physical Environment tools have been updated, including the Kitchen Tracer, Document Review Tool, Building Tour Guide, and Ambulatory and Business Occupancy Building Tour Guide.

There are also two new tools addressing construction and hyperbaric facilities.

Joint Commission also clarified that while the Life Safety survey activity schedule has been reorganized in the revised guide, the actual survey activities have not changed. Organizations should still review the updated guide to become familiar with where information is now located.

Field Impact
We recommend that Facilities leaders review the actual tools rather than simply reading the announcement.

The revised Document List and Review Tool are particularly useful for preparing for the next survey. Organizations with active construction projects or hyperbaric services should also become familiar with the new tools.

Is Your Physical Environment Documentation Ready for Survey?
The October EC News includes a useful review of the documentation that surveyors may request during the Physical Environment portion of a survey.

Most Facilities leaders are familiar with the required inspection, testing, and maintenance records. However, the article is a good reminder that you can expect the surveyors to also request:

• Life Safety drawings
• Fire response plans
• Fire drill records
• Monthly firefighters’ emergency operation testing
• ILSM policies, and documentation of active waivers or equivalencies
• Water management plans
• Workplace violence prevention documentation
• Environmental suicide risk assessments
• Hazardous materials information

Field Impact — A Good Opportunity for a Documentation Check
We recommend that Facilities leaders use the revised Document List and Review Tool to conduct a quick self-assessment.

Are all the required documents readily available? Are inspection and testing records current? Are deficiencies and corrective actions documented?

This is an especially useful exercise for newer Facilities leaders who may not have experienced a Joint Commission survey.

Elevator Testing: Are You Getting All the Records You Need?
The October EC News also includes a Q&A about inspection, testing, and maintenance requirements for elevators and other transport systems.

This is worth a look, particularly if your organization relies on an outside contractor to perform the required testing.

Field Impact
We recommend selecting a few elevators and reviewing their documentation with your Facilities team.

Can you locate the monthly testing records? Is the annual testing current? Has the five-year testing been completed when required? Are deficiencies documented as corrected?

Remember, having a maintenance contract does not necessarily mean all required testing and documentation are complete.

A Practical Checklist for Preventing Slips, Trips, and Falls
Joint Commission has also published a checklist addressing environmental conditions that contribute to falls involving patients, staff, and visitors. There is nothing particularly new about these hazards, but the checklist provides a useful reminder of conditions that can be overlooked during routine rounds.

Field Impact
Consider incorporating the checklist into your Environment of Care rounds. The important question is not just whether hazards are identified, but whether they are corrected.

ACHC: Have You Considered Lithium-Ion Batteries in Your Fire Response Plan?
While not a new requirement, ACHC recently published an article discussing the fire risks associated with Lithium-ion batteries and the importance of including battery-related incidents in fire response planning. This is a wake-up call to mention that lithium-ion batteries are now found throughout healthcare facilities, including medical equipment, maintenance tools, portable devices, and personal electronics.

One point worth considering is that a battery failure may initially involve overheating, smoke, or off-gassing rather than visible flames. Staff need to recognize when the situation requires activation of the organization’s fire response procedures.

The article is a useful resource for Facilities, Safety, Security, and Emergency Management leaders.

Field Impact
We recommend reviewing your fire response plan to determine whether staff would know how to respond to an overheating or smoking lithium-ion battery.

Regardless of who you are accredited by, consider adding a battery failure scenario to a fire drill or emergency response exercise. This is an opportunity to evaluate alarm activation, communication, smoke containment, and protection of nearby patients.

Source: ACHC — Lithium-Ion Batteries and the Fire Response Plan

DNV: CMS Renews DNV’s Hospital Accreditation Authority Through 2032
CMS has renewed DNV Healthcare’s approval as a national hospital accrediting organization for another six years.

Field Impact
There is nothing DNV-accredited hospitals need to do in response to this announcement.

Source: CMS Federal Register Notice

Changes in the Electronic Reporting Process for Deaths Associated with Restraint or Seclusion
CMS has updated the process hospitals use to report deaths associated with restraint or seclusion. The September 21, 2026, revision to QSO-20-04-Hospital-CAH DPU moves the electronic reporting process for Form CMS-10455 from Qualtrics to iQIES.

The reporting requirements under 42 CFR §482.13(g) have not changed, but hospitals will need to use the new platform. We have learned there is an unintended omission on the new form 10455 in that there is no checkbox in the “restraint type” section for mitts or mittens.

CMS has told us that until they are able to make a correction to the form, hospitals should check the box labeled “Other Physical Holds” even though mitts are obviously not a physical hold. Remember that the date and time the report is submitted to CMS must also be documented in the patient’s medical record.

This is a good time to remind everyone that CMS and state surveyors pay close attention to restraint documentation and death reporting. Reporting errors or missed deadlines can create significant compliance concerns.

Field Impact — Make Sure Your Restraint Committee and Clinical Leaders Are Aware
We recommend bringing this update to your next Restraint Committee meeting. Review the new reporting process, update any policies or instructions that still reference Qualtrics, and make sure staff know who is responsible for submitting reports.

Be sure to educate the clinical managers who may be involved in restraint-related death reporting, particularly in the Emergency Department, ICU, and Behavioral Health units. These are not requirements that come up every day, so it’s worth making sure everyone knows the process before a report needs to be submitted.

Sources: Revised QSO-20-04-Hospital-CAH DPU, September 21, 2026

Source: CMS — Electronic Form CMS-10455