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Hospital Accreditation

Hospital Accreditation: Interim Life Safety Measures
Posted by
on 8/1/2017 10:00:00 AM
It was a typical building tour during survey. The CMS fire marshal was touring the kitchen and noticed that the fire suppression system over the grill area was tagged as being out of service. Hospital staff explained that the system had been tested the month before, and needed repair. Parts were on order and repairs were scheduled to be completed in two weeks.
That was fine said the surveyor, who then asked the hospital for evidence that an assessment had been conducted to determine if interim life safety measures (ILSM’) were necessary, and – if so – what measures had been implemented. Staff responded that no such assessment had been performed, and no ILSM measures implemented. The hospital sustained a condition-level deficiency on the spot!
What are Interim Life Safety Measures?
CMS and accrediting organizations require hospitals to be in compliance with the National Fire Protection Association (NFPA) Life Safety Code (LSC). The LSC is a series of directives designed to assure that buildings are constructed and maintained in a way that prevents the origination or spread of fire. When one or more of these directives is not in place, hospitals must implement interim measures to compensate for the increased risk. There are 13 basic measures:
  1. Notify the fire department (or other emergency response group) and initiate a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building
  2. Post signage identifying the location of alternative exits to everyone affected
  3. Inspect exits in affected areas on a daily basis
  4. Provide temporary but equivalent fire alarm and detection systems for use when a fire system is impaired
  5. Provide additional firefighting equipment
  6. Use temporary construction partitions that are smoke-tight or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire
  7. Increase surveillance of buildings, grounds and equipment, giving special attention to construction areas and storage, excavation and field offices
  8. Enforce storage, housekeeping and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level
  9. Provide additional training to those who work in the hospital on the use of firefighting equipment
  10. Conduct one additional fire drill per shift per quarter
  11. Inspect and test temporary systems monthly
  12. Conduct education to promote awareness of building deficiencies, construction hazards and temporary measures implemented to maintain fire safety
  13. Train those who work in the hospital to compensate for impaired structural or compartmental fire safety features
When are ILSM’ required?
There is a common misconception that ILSM’ are only required during periods of building construction or renovation. This is simply not true. ILSM’ can be required whenever there is a deficiency to compliance with the LSC – even when no construction or renovation is involved.
Do ILSM’ have to be implemented for any LSC deficiency?
Not necessarily. That is the whole purpose of conducting an assessment. For minor localized deficiencies such as an isolated smoke compartment door that doesn’t self-latch, your hospital may determine that no ILSM’ need to be implemented while awaiting repair or adjustment to the door. More significant issues – such as the kitchen suppression system mentioned earlier – will require ILSM’.
Does a hospital have to conduct an assessment for needing ILSM’?
Absolutely! CMS and accrediting organizations expect that an assessment is performed each time a deficiency to the LSC is identified. Again, the results of the assessment determine if ILSM’ need to be implemented. Needless to say, the assessment must be documented.
If the assessment determines that ILSM’ are required, does the hospital have to implement all of them?
A hospital is not required to implement each and every measure for a deficiency. The decision on which measures to implement, however, must be criteria-based. A hospital cannot leave such determination to the whims and vagaries of staff and leadership. Surveyors will look to see that your hospital has a criteria-based approach that is codified in some fashion.
Does the implementation of ILSM’ have to be documented?
For the most part – yes. The old adage of “not documented, not done” applies to ILSM’ as well. Unless CMS or an accreditor specifically indicates that all or a specific ILSM’ does not need to be documented, the expectation is that the hospital can prove ILSM’ were, in fact, implemented.
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About the Author

Richard Curtis RN, MS, HACP
RN, MS, HACP

Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
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