Jul 14 2017

ILSM Implementation

Category: ILSM,Questions and AnswersBKeyes @ 12:00 am
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Q: During our last survey the life safety code specialist discovered that 2 of our stairwells were deficient as far as the fire-rating. The contractor did a lousy job as far as the 2-hour rating in 1985 and I guess no one caught it since then, including myself! So 30 years later thanks to the sharp eyes of our surveyor, we will fix it and it’s not going to be walk in the park. My question is: Do we need to do fire watch and additional ILSM fire drills be sufficient?

A: You have an apparent Life Safety Code deficiency. You must assess that deficiency for alternative life safety measures (aka Interim Life Safety Measures, or ILSM), in accordance with your ILSM policy. This is a must, regardless who your accreditation organization is. This assessment must be made on the day that you discover the LSC deficiency.

Your ILSM policy must dictate what measures you will implement (if any) for what particular LSC deficiency. It is important to understand that the policy decides what measures to implement; not a person. In other words, it is pre-determined in the ILSM policy what interim life safety measures will be implemented long before the deficiency is discovered. This removes the human element of making the incorrect decision. It also eliminates the common problem that only the Safety Officer can decide what ILSM to implement. Once it is identified in the ILSM policy, anyone can implement the proper measures.

That said, a Fire Watch is usually reserved for a deficient fire alarm system or a deficient sprinkler system, so typically, a Fire Watch would not be implemented for a defective stairwell construction. Additional ILSM fire drills are a possibility, but usually additional fire drills are implemented when there is a change in exiting that staff needs to be aware of. If this stairwell is closed or an alternate egress route is indicated, then I could see additional ILSM Fire Drills would be appropriate.


Apr 24 2017

Cable on Sprinkler Pipe

Category: ILSM,Questions and Answers,SprinklersBKeyes @ 12:00 am
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Q: We have some sprinkler piping that runs the length of the hall with multiple wires wrapped around the pipe. There is no way of removing the wiring from the pipe unless we perform some major sprinkler pipe removal and reinstallation. This has been identified in a mock survey and we need to come up with a plan of action. How do you recommend we deal with this?

A: Well… you really need to remove the cables and wires from the sprinkler pipe. If you don’t, then you are non-compliant with NFPA 25-2011, section 5.2.2.2.2.

However, here is one other possibility: Do a risk assessment; determine what risks there are to the sprinkler pipe that has cable surrounding it. (I suspect you will find there are no risks, or at least, minimal risks). If your risk assessment identifies any mitigating factors, then implement those mitigating factors. In other words, remove the cable from the sprinkler pipe the best that you can.

If you cannot remove all of the cable from the sprinkler pipe then I suggest you assess it for ILSMs and let it be. Wait for it to be cited during a survey, then submit a waiver request as part of your plan of correction. I suspect the accreditation organization would likely transfer the waiver request on to the respective CMS regional office and they would approve it, provided you demonstrated a significant hardship.


Sep 25 2015

Extra Fire Drills for ILSM

Category: Fire Drills,ILSM,Questions and AnswersBKeyes @ 12:00 am
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Q: Joint Commission standard LS.01.02.01, EP 11 requires the hospital to perform an additional fire drill during periods of Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction. This standard goes on to say that the need for additional fire drills is based on the criteria in the hospital’s ILSM policy. Let’s suppose that a hospital has deficiencies in the Life Safety Code that lasts only for two, three, four days or maybe even a week. Would the hospital still be required to perform an additional drill for such a short duration of Life Safety Code deficiency? What if the hospital’s Safety Committee decides to state that as part of their ILSM policy criteria, it won’t conduct an additional fire drill per shift per quarter unless the Life Safety Code deficiency lasts beyond a certain amount of time, say maybe a month. It seems to me that a Safety Officer would be on the hook for an additional drill per shift per quarter if ILSMs are only in place for a week is overkill and would serve only to further desensitize staff to its fire alarm system.

A: Joint Commission’s standard LS.01.02.01, EP 11 is not prescriptive, meaning they choose not to specify when the extra fire drill needs to start to compensate for a certain deficiency. They don’t even tell you which deficiency the extra fire drill is even required. That is left up to you to decided and state in your ILSM policy.

I tend to think like you, in that the extra fire drill per shift per quarter does not make sense for a short-term LSC deficiency. But when is a LSC deficiency short-term and when is it considered long term? Perhaps a better approach is to ask: “When will the extra fire drill per shift per quarter be required?” Once you decide when the extra fire drill is required, that should help you decide how soon you need to implement the extra fire drill.

When I was the Safety Officer at the hospital where I worked, I felt the extra fire drill was needed when an exit was obstructed or the access to an exit was obstructed. The reason I believed this, is when you do a fire drill one of the items you are assessing is that staff knows the proper way to evacuate patients (using simulated patients, of course). If the path is obstructed, they need to know the alternative path and be able to demonstrate that. The extra fire drill should assesse the staff’s knowledge on evacuation routes.

Some LSC deficiencies aren’t as obvious so you need to ask yourself “Should I conduct an extra fire drill for this deficiency?” for all of the possible scenarios of LSC deficiency that you could have. Set up a Q&A for all the potential LSC deficiencies that you may encounter at your hospital, then ask yourself is an extra fire drill necessary. Here is an example:

  • Failed fire dampers?                                                   I would say no.
  • Obstructed exit?                                                          I would say yes.
  • Unsealed penetrations in a fire/smoke barrier?          I would say no.
  • Fire alarm pull stations not working?                         I would say yes.
  • Smoke detectors not working?                                  I would say no.
  • Obstructed access to an exit?                                     I would say yes.
  • An inoperative fire pump?                                         I would say no.

Ask yourself: “Would the staff benefit from an extra fire drill if this feature of life safety was not working?” I would say obstructed exits, obstructed access to exits, and inoperative fire alarm pull stations are easy to say ‘yes’ to… but the others? I’m not so sure as I don’t think the staff would benefit from an extra fire drill for an inoperative fire pump, or a failed fire damper. The next question is: “When do I begin the extra fire drills?” Well, if you have defective pull stations or an obstructed exit, you are going to do education and awareness training to the staff affected by these deficiencies. The purpose of the extra fire drill is to assess the staff’s knowledge of these LSC deficiencies after you have conducted the education and training. So, what is reasonable for an obstructed exit? A month after the exit became obstructed? I would say not. Maybe a week after the exit becomes obstructed, but I would say not any more than a week. The sooner the better, as you (the Safety Officer) want to know for sure that the staff knows about the LSC deficiency and takes appropriate alternative action. But this is my opinion, and you need to take this to your Safety Committee and let them offer their suggestions before you finalize your policy. Document this assessment in the form of a matrix, spread sheet or a written narrative in your ILSM policy, and have your Safety Committee review it and approve it. Then the surveyor can only hold you to what your policy says you should do.

Just as a reminder… The extra fire drills for ILSM purposes need to be conducted in the area(s) affected by the LSC deficiency. That means if you have an obstructed exit discharge due to construction, you need to perform the extra fire drills in all areas affected by the deficiency. That may mean you are doing multiple extra fire drills per shift per quarter, until the LSC deficiency is resolved. Also, each fire drill needs to activate the building’s fire alarm system, but during the hours of 9:00 pm and 6:00 am you are not required to activate the audible signals on the fire alarm system.


May 19 2014

Interim Life Safety Measures

Category: Business Occupancy,ILSM,Questions and AnswersBKeyes @ 5:00 am
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Q: Are Interim Life Safety Measures (ILSMs) required in Business Occupancies due to construction or life safety code deficiencies? Do we have to conduct a fire watch in Business Occupancies?

A: Yes, interim life safety measures are required for any impairment to a life safety deficiency, regardless of the occupancy type. This is based on two specific requirements. 1) Section 4.6.10.1 of the 2000 edition of the Life Safety Code describes alternative life safety measures (which are the same thing as ILSM) as a general requirement for all occupancies. It is not specific for just healthcare occupancies. 2) Also, if you are Joint Commission accredited, the overview to their Life Safety (LS) chapter says section LS.01.02.01 on ILSMs is applicable to all occupancies.


Apr 28 2014

ILSM on Fire Door Replacement

Category: Doors,Fire Rated Barriers,ILSM,Questions and AnswersBKeyes @ 5:00 am
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Q: If renovation requires replacement of fire doors in multiple areas of the hospital, and must be completed in a short period of time, what would be appropriate interim life safety measures? This would cover multiple areas of the hospital.

A: Appropriate Interim Life Safety Measures (ILSM) for replacing multiple fire doors in a hospital all at the same time would be determined by hospital’s ILSM policy. According to Joint Commission’s standard LS.02.01.01, EP 3, the ILSM policy must include criteria for evaluating when and to what extent the hospital follows special measures to compensate for life safety risks. What this means is the hospital gets to decide what ILSM measures to implement for which life safety impairments, within reason. But, to directly answer your question, I would think the following measures should be considered for implementation:

  • Staff education:  Issue a memo to all departments that are affected by the fire door replacement, notifying them of alternative routes for exiting.
  • Temporary construction partitions: Fire retardant plastic sheeting needs to be installed to contain dust and dirt during the demolition and construction phase of the fire door replacement project.
  • Issue additional fire extinguishers: Place extra fire extinguishers in the project area and provide instructions to the construction workers on how to operate them
  • Daily surveillance: Daily surveillance to ensure the fire door project area is clean and free from debris should be performed, as long as the project is active.
  • Post signage: If the project to replace the fire doors blocks access through the egress corridor in that area, then signage should be posted indicating the nearest alternative exit.
  • Fire watch: If any portion of the fire alarm system or the sprinkler system is impaired for 4 or more hours in a 24 hour period due to the fire door replacement project, notification of the local fire department is required and a fire watch must be performed


Mar 04 2013

Temporary Storage in Patient Rooms

Q: We have a short-term project where we need to find some space to store equipment until they are installed. The equipment is electronic and needs to remain in their cardboard boxes until it is installed. We think we need to store these items for 6 – 8 weeks. Can we use patient rooms that are not in service as temporary storage areas?

A: Your question is more like “Can we violate the Life Safety Code (LSC) for a short period of time?” In some situations you are permitted to violate the LSC. Section 4.6.10.1 of the 2000 edition of the LSC says you are permitted to occupy the building during construction, repair, alterations, or additions where alternative life safety measures (aka Interim Life Safety Measures), which are acceptable to the authority having jurisdiction, are in place. If the equipment that you wish to store in the out-of-service patient rooms qualifies as construction, repair, alterations or additions, then I would say you have a legitimate position, as long as you implement alternative life safety measures. The measures that you implement should be in accordance with your policies.  However, out-of-service patient rooms cannot be used for storage of combustibles (in this situation, the cardboard boxes would be considered combustible) that is not associated with construction, repair, alteration or additions. The reason is most patient rooms are not constructed to meet the requirements for hazardous storage rooms. Make sure you perform the alternative measures and document each inspection.


Sep 01 2010

ILSMs for Business Occupancies

Category: ILSM,Questions and AnswersBKeyes @ 5:11 pm
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Q: What ILSM’s apply to occupancies other than healthcare? For example, if a fire alarm/sprinkler system is out of service for more than 4 hours in a 24 hour period in one of our freestanding physician practices, we notify the local fire department.  What about other ILSM’s such as altered exits, etc?

A: It is a NFPA Life Safety Code requirement, as you state, to notify the local fire department AND conduct a fire watch whenever the fire alarm system (or part of the system) and the sprinkler system (or part of the system) is out of service  for 4 or more hours in a 24 hour period (LSC 9.6.1.8 and 9.7.6.1). Therefore, that action is required for any and all buildings subject to the NFPA Life Safety Code. This would include all healthcare occupancies, ambulatory care occupancies, business occupancies, etc. The Interim Life Safety Measures that you refer to are a product of the Joint Commission standards, and therefore, only apply to those buildings which the Joint Commission says it needs to apply to. Their Hospital Accreditation Standards manual, and their Ambulatory Health Care manual both require ILSMs to be implemented in healthcare occupancies, and ambulatory care occupancies, but does not require them in any other occupancy type. Therefore, one could conclude that ILSMs do not need to be implemented in business occupancies. However; many business occupancies that are contiguous to the main hospital are staffed with people who have come to expect the same level of fire protection in their building as the main hospital. Therefore, it is wise to go beyond the minimum requirements and implement ILSMs in those business occupancies that have a close tie with a healthcare or ambulatory care occupancy. To address your last question, an altered exit in a free-standing physician office which qualifies as a business occupancy, would not require an ILSM, although it would be wise to implement ILSMs


May 01 2009

Interim Life Safety Measure Implementation

Category: ILSM,Questions and AnswersBKeyes @ 1:43 pm
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Q: The Joint Commission’s standard on Interim Life Safety Measures (ILSM) requires the hospital to implement ILSM for deficiencies to the Life Safety Code (LSC) when the deficiency cannot be immediately corrected. Please define the time-frame that they mean with the word “immediately”. Can the implementation of an ILSM wait until the Safety Committee approves it?

A: The implementation of an ILSM cannot wait for a committee’s review and approval. The intent of the word “immediate” suggests that the ILSM must be implemented as soon as it is determined the deficiency cannot be resolved the moment it is discovered. This means to me that you need to implement an ILSM the same day a deficiency is discovered.

Each hospital is required to have a written Interim Life Safety Measure policy that applies to situations when LSC deficiencies cannot be immediately resolved due to equipment failure, maintenance, or construction. Your policy should proactively identify the process in which you meet the 11 different prescriptive requirements found in the standard. By following your own policy, your staff should be able to determine which measure to implement based on the deficiency that was discovered. This implementation phase may be approved by someone in authority at your facility, but it should not be held up for approval by a committee. However, it is encouraged that all ILSMs be presented to your Safety Committee as evidence of your organization managing the life safety deficiency. This will foster general discussion which should be reflected in your committee’s minutes.

Be very conservative with the implementation of ILSMs. Failure to implement appropriate ILSMs can lead to an adverse decision at your next survey.