Managing the Interim Life SafetyMeasures (ILSM) Process1A Program forThe Texas Association of Healthcare Facility ManagementMonday, April 30, 2012Robert H. Bartels, CHFM CHSP CHEP SASHE – President,S f MSafetyManagement SServices,iIInc SMS, Inc., 2012
Managing the ILSM Process2Element of Performance LS.02.01.01 EP 3 Requires:“TheTh hospitalh i l hash a writteniInterimIi LifeLif SafetyS f MeasureMpolicy that covers situations when Life Safety Codedeficiencies cannot be immediately corrected or duringperiodsi d off construction.i TheTh policyli includesi l d criteriai i forfevaluating when and to what extent the hospital followsspecial measures to compensate for increased life safetyrisk.k (see(alsol LS.S 01.01.0101 01 01 ep3)”3)” SMS, Inc., 2012
Managing the ILSM Process3y This EP causes a situational decision rule to beinvoked: It results in Automatic Conditional Accreditation It can leadl d tot Non-AccreditationN Adit ti It is one of only two (2) of the 442 EP’s that can cause this SMS, Inc., 2012
Managing the ILSM Process4y “ when Life Safety Code deficiencies cannot becorrected immediately.” According to the Standards Interpretation Group (SIG):“Immediately”Immediately means if not corrected on the shift it wasdiscovered SMS, Inc., 2012
Managing the ILSM Process5y “When and to what extent the hospital followsspecial measures to compensate for increased LifeSafety risk” This means the organization chooses If they need to do any ILSM measures If so, which measures? How & how often they perform them SMS, Inc., 2012
Managing the ILSM Process6y ILSM Measures LS.01.02.01 EP1 – The hospital notifies the fire department (or otheremergency response group)) andd initiatesi iti t a firefi watcht hwhen a fire alarm or sprinkler system is out of servicemore than 4 hours in a 24-hour period in an occupiedbuilding. Notification and fire watch times aredocumented. (For full text and any exceptions, refer toNFPA 101101-2000:2000: 188.8.131.52 6 1 8 & 184.108.40.206)9 7 6 1) (See alsoLS.01.01.01. EP 3) SMS, Inc., 2012
Managing the ILSM Process7y ILSM Measures LS.01.02.01 (cont.) EP2 – The hospital posts signage identifying the locationof alternative exists to everyone affected. (See alsoLS.01.01.01, EP 3) SMS, Inc., 2012
Managing the ILSM Process8y ILSM Measures LS.01.02.01 (cont.) EP3 – The hospital has a written interim life safety measure(ILSM) policy that covers situations when Life Safety Codedeficiencies cannot be immediately corrected or duringperiods of construction. The policy includes criteria forevaluatinglwhenh andd to whath extent theh hospitalhl followsf llspecial measures to compensate for increased life safetyrisk. ((See also LS.01.01.01, EP 3)) SMS, Inc., 2012
Managing the ILSM Process9y ILSM Measures LS.01.02.01 (cont.)When the hospitalpidentifiesf Life Safetyy Code deficienciesfthatcannot be immediately corrected or during periods ofconstruction, the hospital does the following: EP4 – InspectsIt exitsit ini affectedff t d areas on a dailyd il basis.b iThe need for these inspections is based on criteria in thehospital’s interim life safety measure (ILSM) policy. (Seealso LS.01.01.01, EP 3) SMS, Inc., 2012
Managing the ILSM Process10y ILSM Measures LS.01.02.01 (cont.) EP5 – Provides temporary but equivalent fire alarmand detection systems for use when a fire system isimpaired. The need for equivalent systems is based oncriteriait i ini theth hospitalh it l’s interimi t i lifelif safetyf t measure(ILSM) policy. (See also LS.01.01.01, EP 3) SMS, Inc., 2012
Managing the ILSM Process11y ILSM Measures LS.01.02.01 (cont.) EP6 – ProvidesP id additionalddi i l firefightingfi fi h i equipment.iTheThneed for this equipment is based on criteria in thehospital’s interim life safety measure (ILSM) policy. (Seealso LS.01.01.01, EP 3) S e (EC) Committee. SMS, Inc., 2012
Managing the ILSM Process24Sample ILSM Policy (cont.)ILSM Assessment Tool Instructions1. Evaluate the project or deficiency for impact on exiting, compartmentation, fire detection andresponse systems, ignition sources, storage, debris, and other potential concerns identified thecriteria.2. Determine if the impact is significant. In general, projects that are less than a week in length,which do not reduce the level of life safetyy below Life Safetyy Code minimum requirements,q, arenot significant. An activity which takes place in a room with an intact door and which does notpenetrate walls, generally does not require an ILSM. Activity that affects doors or walls for lessthan one shift generally does not require an ILSM. Activities that block or compromise exit stairs,requiredqexit corridors,, or exit dischargeg areas for more than one shift generallygy requireqan ILSM.3. If it is determined that an ILSM is warranted, monitor and document that the ILSM is in-placeand functioning as required. If the ILSM is not functioning as required, adjust the ILSM or reassess the situation.4 Document and submit findings to the EC Committee or designated sub-committee.4.sub committee5. Document enforcement of each required ILSM when appropriate. SMS, Inc., 2012
Facility Name Interim Life Safety Measures Assessment ToolProject Name:Project Date:Preparer:Risk # Risk Elements SMS, Inc., 2012Location:Date:25LS-1Will existing exits be impaired?a. alternative exits be necessary?b.existing corridor width be reduced?c construction area escape routes be needed?c.constructionLS-2Will existing fire safety systems be impaired?a. existing fire alarm system be impaired?b. existing fire detection system be impairedc.existing sprinkler system be impaired?d. temporary or equivalent systems be needed?LS-3Will additional fire fighting equipment be needed?LS-4Will temporary, smoke–tight construction partitions that arenon-combustible or limited-combustible be needed?LS-55LSWill increased hazard surveillance of patient buildings beneeded?a.hazard surveillance of buildings, grounds or equipmentb.special attention to excavations, construction storage orwork areas.LS-6Will reduction in the flammable or combustible fire load beneeded?a. temporary construction storage be neededb. housekeeping or debris removal be needed?LS-7Will additional fire response training be needed?LS-8Will additional fire drills be needed?LS-10Will it be needed to inspect and test temporary systemsmonthly and document inspection informationLS-10Will organizational training in LSC deficiencies, constructionhazards be needed?LS-11Will training to compensate for structural orcompartmentation deficiencies be needed?YesNoSuggest Controls
Facility Name Interim Life Safety Measure Inspection FormProjectPj t Name:NInspection Date:Conducted by:Control #LS-1LS-2LS-3LS-4LS-5LS-6LS-7LS 8LS-8LS-9LS-10LS-11 SMS, Inc., 2012LLocation:tiDate:RequiredYes NoControlsInspect exits in affected areas on a daily basis to ensureclear exits. Identify new exits if necessary.Provide temporary but equivalent fire alarm anddetection systems for use when a fire system isimpaired.Provide additional fire-fighting equipment.Use temporary construction partitions that are smoketight, or made of noncombustible material, or made oflimited combustible material that will not contribute tothe development or spread of fire.Increase surveillance of buildings, grounds, andequipment, giving special attention to construction areasand storage, excavation, and field offices.Enforce storage, housekeeping, and debris removalpractices that reduce the building’s flammable andcombustible fire load to the lowest feasible level.Provide additional training to those who work in thehospital on the use of fire-fighting equipment.C d t one additionalConductdditi l firefi drilld ill per shifthift per quarter.tInspect and tests temporary systems monthly. Thecompletion date of the tests is documented.Conduct education to promote awareness of buildingdeficiencies, construction hazards, and temporarymeasures implemented to maintain fire safety.Train those who work in the hospital to compensate forimpaired structural or compartmental fire safetyfeatures.26StatusComment
ILSM QuickCheck Deficiency Description SMS, Inc., 829Occupancy SSeparation ComprommisedTravel Distaance IncreasedExit Route CClosedFire Suppresssion ImpairedILSMRequiredFire Alarm IImpairedDeficiencyNumberY27NComments
ILSM QuickCheck ILSMRequiredFire Suppression ImpairedompromisedExit Route CoTravel Distancce IncreasedOccupancy Sepparation CompromissedDeficiency DescriptionFire Alarm ImmpairedItem#NNNNNNNNNNNNNNNNNYNNNNNNNNNNNNNNNNNY SMS, Inc., ke door closer broken outside E326Room wall penetration by W248Room door latch broken W567Exit stair 3E inaccessibleICU entry doors gap 1/8”Fire extinguisher missing 2W hallwayExit light b W742 burned out28NXXXXXXXComments
Managing the ILSM Process29y Include Life Safety Code items identified during: SMS, Inc., 2012Life Safety/SOCySurveysyThe Joint Commission SurveysCMS SurveysState & Local InspectionsEnvironmental Tours45 DayD LiListtInsurance Inspections
appropriate Interim Life Safety Measures (ILSM)appropriate Interim Life Safety Measures (ILSM). PURPOSE Interim Life Safetyy() pyp Measures (ILSM) are administrative actions taken to temporarily compensate for the hazards posed by construction activities or any time the fire pro
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