Q: Our hospital has a few offsite locations – family practice clinic, occupational health clinic, and soon to be an urgent care clinic. It is my understanding that these facilities are considered a business occupancy. They are not licensed as a department of our hospital. Do they need Interim Life Safety Measures (ILSM) for construction projects?
A: Yes, all construction projects should be evaluated for Alternative Life Safety Measures (ALSM), also known as Interim Life Safety Measures, regardless in what building they are conducted. This is a requirement of section 220.127.116.11 of the 2012 Life Safety Code, to evaluate any impairment of a life safety feature for consideration of implementing compensating measures. Even if an accreditation surveyor does not make an onsite assessment of the facility, the organization is still obligated through section 18.104.22.168 to conduct an ALSM risk assessment.