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Interim Life Safety Measures (ILSM'S) : Assessment and Implementa9on – AHCA, Joint Commission & CMS Compliance.
Presented by Jack L. Waisblat – President JT Service Contractor Corp. and Mark Slazinski -‐ AHCA
September 26, 2011
Overview
• What Is it? • Who requires it? • Why is it required? • When is it required? (Condi3ons Requiring ILSM’S) • ILSM Elements of Performance. • ILSM Implementa3on. • Incorpora3ng Architectural / Engineering Design Elements – Up Front.
• Referenced codes. • Referenced forms / policies and procedures. • Q & A
What is it (purpose)?
Interim Life safety Measures (ILSM) are measures that are implemented to assure the
safety of all building occupants during periods when elements of the life safety code and building codes are compromised
due to construc9on, impairment of fire safety systems, failure of fire safety systems or
discovery of a life safety code / building code deficiency.
Who Requires it? The requirement for implemen9ng ILSM measures are
mandated by the following: • NFPA 1 (fire preven9on code), 7-‐3.6
• NFPA 1, 29-‐2.16.8.1 • NFPA 25 (Inspec9on, Tes9ng, and Maintenance of Water-‐Based
Fire Protec9on Systems); chapter 14 (Impairments), 14.1 • NFPA 101 (the life safety code); chapter 4, 4.6.10 (Construc9on,
Repair, and Improvement Opera9ons). • NFPA 101; chapter 9, 9.6.1.8 (Fire detec9on, alarm and
communica9on systems). • The Joint Commission; CAMH, Life Safety Chapter, LS.01.02.01.
• CMS; Condi9ons of par9cipa9on, 482.41 (b) • AHCA
• DNV; PE.2, SR.7
Why is it required?
To compensate for: • Demoli9on of rated walls during construc9on. • Construc9on affec9ng egress and exi9ng. • Construc9on affec9ng fire safety systems.
• Failure of a fire safety system • Impairments of fire safety systems due to tes9ng,
maintenance and inspec9on ac9vi9es. • Discovery of a life safety code deficiency (non
construc9on project related) that can not be immediately corrected.
When is it required?
A documented ILSM assessment, regardless of establishing the need for implemen3ng requirements of ILSM measures is always
required when any of the previously discussed compromises could possibly manifest
themselves due to construc3on, impairment, failure, or discovery of LSC deficiency. When in doubt; always conducted an
assessment and document it.
ILSM Elements of Performance
The Joint Commission’s standard LS.01.02.01 (The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construc3on) mandates the following 14 elements of performance:
• A 1. The hospital no3fies the fire department (or other emergency response group)and ini3ates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-‐hour period in an occupied building. No3fica3on and fire watch 3mes are documented. (For full text and any excep3ons, refer to NFPA 101-‐2000: 9.6.1.8 and 9.7.6.1) (See also LS.01.01.01, EP 3). (direct impact finding).
ILSM Elements of Performance
• A 2. The hospital posts signage iden3fying the loca3on of alterna3ve exits to everyone affected. (See also LS.01.01.01, EP 3) (direct impact finding).
• A 3. The hospital has a wricen interim life safety measure (ILSM) policy that covers situa3ons when Life Safety Code deficiencies cannot be immediately corrected or during periods of construc3on. The policy includes criteria for evalua3ng when and to what extent the hospital follows special measures to compensate for increased life safety risk. (See also LS.01.01.01, EP 3) (SituaAonal Decision finding).
ILSM Elements of Performance
When the hospital iden3fies Life Safety Code deficiencies that cannot be immediately
corrected or during periods of construc3on, the hospital does the following:
• C 4. Inspects exits in affected areas on a daily basis. The need for these inspec3ons is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3). (direct impact finding).
ILSM Elements of Performance
• A 5. Provides temporary but equivalent fire alarm and detec3on systems for use when a fire system is impaired. The need for equivalent systems is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3) (direct impact finding).
• A 6. Provides addi3onal firefigh3ng equipment. The need for this equipment is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3) (direct impact finding).
ILSM Elements of Performance • A 7. Uses temporary construc3on par33ons that are smoke-‐3ght, or made of noncombus3ble or limited-‐combus3ble material that will not contribute to the development or spread of fire. The need for these par33ons is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3).
• C 8. Increases surveillance of buildings, grounds, and equipment, giving special acen3on to construc3on areas and storage, excava3on, and field offices. The need for increased surveillance is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3).
ILSM Elements of Performance
• C 9. Enforces storage, housekeeping, and debris-‐removal prac3ces that reduce the building’s flammable and combus3ble fire load to the lowest feasible level. The need for these prac3ces is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3).
• A 10. Provides addi3onal training to those who work in the hospital on the use of firefigh3ng equipment. The need for addi3onal training is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3).
ILSM Elements of Performance
• A 11. Conducts one addi3onal fire drill per shig per quarter. The need for addi3onal drills is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also EC.02.03.03, EP 1; LS.01.01.01, EP 3).
• C 12. Inspects and tests temporary systems monthly. The comple3on date of the tests is documented. The need for these inspec3ons and tests is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3).
ILSM Elements of Performance • A 13. The hospital conducts educa3on to promote awareness of building deficiencies, construc3on hazards, and temporary measures implemented to maintain fire safety. The need for educa3on is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3) (direct impact finding).
• C 14. The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features. The need for training is based on criteria in the hospital’s interim life safety measure (ILSM) policy. (See also LS.01.01.01, EP 3) (direct impact finding).
ILSM Implementa3on Elements
• Must Have a wricen and approved ILSM policy and procedure (that follows the 4 steps on the next slide). • The policy and procedure must ar3culate criteria of when you conduct ILSM evalua3ons and to what extent you follow (implement) special measures to compensate for increased life safety risk due to compromises.
ILSM Implementa3on Elements
The Interim Life Safety Measures Process Should Include the Following 4 Steps:
• Step 1; Is an ILSM evalua3on required? Yes / No (I recommend that an evalua3on always be required; regardless of scope, magnitude or dura3on).
• Step 2; If Yes, does the ILSM evalua3on require the implementa3on of ILSM? Yes / No.
• Step 3; If Yes, which interim measures apply? • Step 4; Implement and document the required measures.
ILSM Implementa3on Elements • All Plan for Improvement (PFI’S) require an ILSM assessment (unless you can correct the deficiency immediately).
• All 45 day PFI’S require an ILSM assessment. • Conduc3ng a main drain test that lasts longer than 4 hours requires ILSM, fire watch and no3fica3on of fire dept.
• A defec3ve fire pump that can not be repaired in less than 4 hours requires ILSM, fire watch and no3fica3on of fire dept.
ILSM Implementa3on Elements
• Taking a fire alarm system out of service for longer than 4 hours requires ILSM, fire watch and no3fica3on of fire dept.
• Construc3on project reduces the numbers of stairs that discharge to the outside to less than 50%.
• Hot work is being performed. • Bypassing func3ons of the fire alarm system for tes3ng purposes (audio, visual, fan shutdown, elevator recall, fire and smoke door closure, etc.).
Incorpora3ng Architectural / Engineering Design
Elements – Up Front
• Interface with the Facili3es management dept. (FMD) prior to start of DD documents.
• Find out what the hospital FMD deems as a set a life safety plans that they present to AHCA, valida3on surveys, TJC surveys; consider elements of those plans into the design.
• Determine if a membrane ceiling is concealing unprotected steel; place correc3ve and ILSM measures into CD’S.
Incorpora3ng Architectural / Engineering Design Elements – Up Front
• Find out from the FMD if equivalencies or waivers have been previously granted by AHCA, TJC, CMS, Local FM.
• A phasing plan, an ICRA / PCRA is not enough; help the FMD with an ILSM assessment before the construc3on project starts.
• Examine the impact of stair reduc3on / discharge on the overall complex; is the hospital s3ll mee3ng the 50% rule (NFPA 101, 7..7.2).
• Examine fire alarm system and sprinkler system zoning; can it only be disabled in the construc3on zone or will it impact areas outside the construc3on zone; how many trouble light will appear on the FACP.
Referenced Codes
NFPA 1 (Fire Preven3on Code): 29-‐2.16.8.1 Where the building is protected by fire protec3on systems, such systems shall be maintained opera3onal at all
3mes during altera3on. Excep3on: Where altera3on requires modifica3on of a por3on of the fire protec3on system, the remainder of
the system shall be kept in service and the fire department shall be no3fied. When it is necessary to shut down the system, the authority having jurisdic3on shall have the authority to require alternate measures of protec3on un3l the system is returned to service. The fire department shall be no3fied when the system is shut down and when the system is returned to service.
NFPA 25, chapter 14 (Impairments). 14.1 General. This chapter shall provide the minimum requirements for a water-‐based fire protec3on system impairment
program. Measures shall be taken during the impairment to ensure that increased risks are minimized and the dura3on of the impairment is limited.
NFPA 101, chapter 4: 4.6.10 Construc3on, Repair, and Improvement Opera3ons. 4.6.10.1* Buildings or por3ons of buildings shall be permiced to be occupied during construc3on, repair, altera3ons, or
addi3ons only where required means of egress and required fire protec3on features are in place and con3nuously maintained for the por3on occupied or where alterna3ve life safety measures acceptable to the authority having jurisdic3on are in place.
Referenced Codes NFPA 101, chapter 9: 9.6.1.8* Where a required fire alarm system is out of service for more than 4 hours in a 24-‐hour
period, the authority having jurisdic3on shall be no3fied, and the building shall be evacuated or an approved fire watch shall be provided for all par3es leg unprotected by the shutdown un3l the fire alarm system has been returned to service.
NFPA 101, chapter 19: 19.1.1.3 Total Concept. All health care facili3es shall be designed, constructed, maintained, and operated to
minimize the possibility of a fire emergency requiring the evacua3on of occupants. Because the safety of health care occupants cannot be ensured adequately by dependence on evacua3on of the building, their protec3on from fire shall be provided by appropriate arrangement of facili3es, adequate staffing, and development of opera3ng and maintenance procedures
Referenced Codes
NFPA 1: 7-‐3.6 Opera3ng Procedures. All automa3c sprinkler systems shall be con3nuously
maintained in a reliable opera3ng condi3on at all 3mes, and such periodic inspec3ons and tests shall be made as necessary to ensure proper maintenance. When an automa3c sprinkler system is out of service for more than four hours within a 24-‐hour period, the building shall be evacuated, or an approved fire watch shall be provided for all por3ons leg unprotected by the sprinkler system shutdown un3l the sprinkler system has been returned to service.
ILSM Assessment Form
ILSM Policy and Procedures
Fire Watch Decision Grid
