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).