The lead article in the February issue of Perspectives addresses interim life safety code measures as required by. This standard is particularly important because EP 3 by itself is associated with an adverse outcome, accreditation with follow up survey, (AFS) if there is a failure to have an ILSM policy and evaluate life safety code deficiencies using that policy.
In years past hospitals got stung by this standard when their ILSM policies and implementation only focused on construction and failed to consider other life safety code defects, such as those items being added to the Part IV, Plan for Improvement or PFI. The Joint Commission has helped to make this clearer in recent years through their many publications, educational programs and now even in the PFI itself where is asks the hospital to identify if the issue has been evaluated for ILSM.
Another point of confusion we have seen in hospitals is a failure to implement any ILSMs unless the fire alarm was shut off for 4 hours or more, in which case the safety measure implemented was a fire watch. This article makes the distinction clear between fire watch (EP 1) and ILSM’s (EP’s 4-14). Fire watch is an absolute requirement if the alarm system or sprinkler system is going to be out of service for 4 hours or more. ILSM’s, or other means of keeping people safe may be needed for other defects or construction and your policy should help shape what you do to keep people safe. A good way to think about this standard is EP’s 4-14 are things we might do, in order to promote fire safety during the timeframe when one or more defects exist. Based on the nature of each temporary defect, your ILSM policy and facilities staff should determine which of the things described in EP’s 4-14 are going to be done to enhance fire safety during this period.
We mentioned that in past years we used to see hospitals fail to evaluate for ILSM. This is seen less often today due to the reminders TJC has issued and the link in the PFI. However, we still often see a failure to document the implementation of the selected ILSM’s. If your policy says you are going to do something, and your risk assessment or decision making process confirmed you were going to do it, then you have to do it and a log or some other suitable documentation should exist to prove that you did it. Sounds simple, but when a project goes on for months, it is too easy to forget the commitment to conducting an extra fire drill (EP 11) or extra rounding to keep an area clean of combustible debris (EP 9).
One last risk point we want to mention for this standard is a failure to evaluate ILSM for Life Safety Code defects which cannot be immediately corrected, but do not trigger a PFI because you believe you can correct the defect within 45 days of discovery. While you can bypass adding the defect to the PFI, you can’t bypass evaluating the defect for ILSM or implementing ILSM as deemed necessary.
This article from Perspectives should be shared with facilities leadership and discussed at their EC committee to verify compliance. The key questions to ask for this self-assessment are:
• Do we have the required policy, which includes construction, and all identified defects?
• Are we evaluating all defects that cannot be corrected immediately (i.e., today)?
• Does our evaluation tool include potential implementation of all enhanced safety measures described in EP’s 4-14?
• Do we have documentation that we implemented ILSM for recent defects as described in our policy?
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