ILSM for Fire Alarm System in Test Mode

Q: If we put the fire alarm system in test by-pass but we are still monitoring the alarms so we can troubleshoot or test the system so we avoid nuisance FA activation do we need an ILSM (Fire watch)?

A: Well… How long do you have it in test mode? More than 4 hours? If so, then I can see where an ILSM assessment is required, but the assessment would identify that the fire alarm system is impaired since it is in test mode, but you have a Fire Watch in effect because you would have someone at the panel constantly until the panel is off test mode.

So… an ILSM assessment would be required after you reach the 4-hour mark, but the assessment should identify that you are doing a Fire Watch my posting a responsible individual at the panel.

Sounds like a paper documentation issue, as you are already doing the Fire Watch.

ILSM in Business Occupancies

Q: Is there a code requirement for implementing an Interim Life Safety Measure (ILSM) for occupancies other than healthcare (i.e. business occupancies) if a life safety code deficiency has been identified?

A: Yes… ILSM (also known as Alternative Life Safety Measures) is found in chapter 4 of the 2012 Life Safety Code, specifically section 4.6.10.1 of the 2012 LSC. This describes the need to implement ALSMs when features of Life Safety are impaired. This chapter is part of the ‘core’ chapters and applies to all occupancy chapters, so that means it applies to business occupancies as well.

Most accreditation organizations should be enforcing this in offsite locations, such as business occupancies. Some surveyors fail to ask for this, but it is an enforceable requirement.

ILSM Fire Drills

Q: I’ve been conducting two fire drills per month while we are under construction. I am new to the safety role and my understanding of the code is that I should be doing 2 per quarter each on different shifts. My facilities guy says 2 per month. Who is correct? I think we are giving our employees alarm fatigue.

A: Fire drills must be conducted as follows for healthcare occupancies (i.e. hospitals) and ambulatory health care occupancies (i.e. ASC):

  • Regular fire drills must be conducted once per shift per quarter, with start times staggered by 2-hours on fire drills conducted on the same shift but on consecutive quarters;
  • ILSM fire drills must be conducted once per shift per quarter in areas affected by the impairment requiring the ILSM fire drill. This drill is in addition to the regular fire drill.

The ILSM fire drill must evaluate each departments response that is affected by the impairment that requires the ILSM fire drill. This may mean you will have more than one ILSM fire drill per shift per quarter.

It appears you are on the right track with 2 fire drills per shift per quarter while the construction is underway. I’m not sure where the facility guy is coming from with the 2 drills per month requirement.

Sprinklers in Lieu of Smoke Detectors

Q: We are seeking to reduce activation of smoke heads contained in our construction areas. In your opinion, if the construction area has existing sprinkler coverage or if new active sprinklers are installed in the construction area, would it be acceptable to remove the smoke heads in this space? In other words, are sprinklers a proper substitute for smoke heads?

A: No… sprinklers are never an acceptable substitute for smoke detectors, because sprinklers do not sense the presence of smoke. Conversely, smoke detectors are never an acceptable substitute for sprinklers because they do not extinguish a fire. However, if the smoke detectors are not required by code or regulation, then they can be removed without any alternative life safety measures applied.

According to 4.6.10.1 of the 2012 Life Safety Code, only deficiencies of required features of life safety necessitate alternative life safety measures (ALSM), also known as Interim Life Safety Measures (ILSM). However, be aware that not all surveyors will likely understand this and they may cite an organization for impaired smoke detectors even if the smoke detectors are not a required feature of life safety.

It is not uncommon for designers to over-install smoke detectors and place them in areas where they are not required. But if the smoke detectors are required, and you desire to remove them for construction purposes (not a bad idea) then you will have to assess them for ALSM and likely implement a fire watch, which can be very costly since it is now required to have a continuous fire watch. Replacing the smoke heads with heat detectors still does not change the result. If the smoke detectors are required then a heat detector is not an acceptable substitute.

Alternative Life Safety Measures

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 4.6.10.1 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 4.6.10.1 to conduct an ALSM risk assessment.

Corridor Obstruction for Construction

Q: Can an existing 8-foot wide corridor be reduced in width to 4 feet by temporary construction barriers?

A: Yes, but you will need to conduct an assessment for Alternative Life Safety Measures (or Interim Life Safety Measures as one accreditation organization calls it). All of the AHJs understand there will be times when you will need to have non-compliance with the Life Safety Code during periods of construction, maintenance, or emergency repairs.

It is understandable that you will need to build a ‘bump-out’ in an existing corridor of an occupied unit, in order to conduct demolition, and reconstruction, which will obstruct the required width of the corridor during the period of construction. The Life Safety Code already has considered this situation and section 4.6.10.1 of the 2012 LSC permits buildings to be occupied during periods of construction provided that ALSMs (or ILSMs) are in place.

So, when you know that the corridor needs to be obstructed for the purpose of construction, you assess the situation for ALSM (ILSM) and you follow what your ALSM (ILSM) policy requires you to do. For a corridor obstruction, it is likely that you would be required to do:

  • Staff education on the obstruction, informing them of alternative routes for exiting
  • Daily inspections, looking for accumulation of debris, supplies or other items
  • An additional fire drill in the affected area to ensure staff understands that an alternate route for exiting is required

There may be other measures that need to be implemented, such as additional education, or additional fire-extinguishment devices. Once the assessment is conducted, it must be recorded and available for review by surveyors.

Interim Life Safety Measures

Q: At our hospital, we had numerous fire dampers that failed their 6-year test. What ILSM measures for that many dampers would you recommend putting in place?

A: You are correct in saying ILSM assessment needs to be made for deficient fire dampers. Many hospitals get into trouble over that and forget to do that, so I’m glad to hear that you are on top of that. What I see some of my clients do for defective fire dampers is to make an ILSM assessment that states “No compensating measures are required”. I would not recommend that, but it appears that will be accepted by some accreditation surveyors. I would recommend at the minimum “Staff Education” as a compensation measure for an ILSM assessment. Send a memo to the staff in the area of the defective fire damper instructing them in the case of a fire, the fire dampers may not operate correctly until you get them repaired. They should take into account the location of the defective fire dampers when determining which direction they will evacuate (if needed).

ILSM Implementation

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.

Cable on Sprinkler Pipe

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.

Extra Fire Drills for ILSM

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.