Transcript The Ins and Outs of Interim Life Safety Measures

ILSMs
Eugene A. Cable, P.E.
Life Safety Consultants
NEHES NFPA Liaison
412 Horse Heaven Road
Averill Park, New York 12018
(518) 794-7237
[email protected]
Introduction
 Background and “Code Creep”

Real World Life Safety Factors

ILSM Standards and Policy
ILSM Definition

Special measures taken to compensate for
increased life safety risk.
– “Code Creep”: When codes and standards are
enforced beyond their true intent.
Background
1996 In the Beginning. . .
 By 2004, TJC standard EC.5.50

– “The organization develops and implements activities to protect
occupants during periods when a building does not meet the
applicable provisions of the Life Safety Code®.
– EP 1. Each organization develops a policy for using interim life
safety measures (ILSMs).

2012, TJC standard LS.01.02.01
– EP 3. “The organization has a written interim life safety measure
(ILSM) policy that covers situations when LSC deficiencies cannot
be immediately corrected or during periods of construction”
Background Code Creep

George Mills and Joint Commission presenters:
– Try to stop creep by emphasizing your policy
– “The ILSM review is driven by your policy”
– “An ILSM policy should be in force during any situation in which a
LSC violation cannot be immediately corrected” (2011 Essentials)



Rest of EP #3, “The policy includes criteria for evaluating
when and to what extent the organization follows special
measures to compensate for increased life safety risk.”
Reason: Easy to just copy the standard into a policy
Reason: Ghost standard spreads quickly
Background

NFPA 101 addresses non-compliance
– Section 4.6.4 Time allowed for compliance
– Section 4.6.9.1 Conditions for occupancy
» No serious life safety hazard exists as judged by the AHJ.
– Section 4.6.10.1 Occupied during construction
» “Buildings. . . shall be permitted to be occupied during
construction, repair,… only where required means of egress
and required fire protection features are in place and
continuously maintained for the portion occupied or where
alternative life safety measures acceptable to the AHJ are in
place.

The Life Safety Code acknowledges that
deficiencies occur all the time.
Real World Life Safety Factors
Life Safety Code

Redundant requirements

Total Concept (Section 18.1.1.3)

Multiple Safeguards
- Prevent Ignition
- Detection of Fire
- Inhibit fire growth
- Confinement of fire and smoke
- Extinguishment of fire
- Fire Dept actions
- Staff action – refuge
- Staff action - evacuate
 Unattended patient bunches up linen on patient bed and
slips hand under the pile
Series of failures

Multiple Safeguards:
- Prevent Ignition
- Detection of Fire
- Inhibit fire growth
- Confinement of fire and smoke
- Extinguishment of fire
- Fire Dept actions
- Staff action – refuge
- Staff action - evacuate
3 X 5 Cards – Quiz
1.
2.
3.
4.
5.
Real World Life Safety Factors

ILSM is really an effort at temporary equivalency, to
introduce a non-required safety element to make up
for one that is required but missing.

Difficult to decide appropriate alternative measures

FSES Equivalency methodology outlines THE major
factors/parameters for life safety.
FSES Life Safety Factors

Patient mobility/ density/ location/staff ratio
– Called the “occupancy risks”

Building safety parameters
–
–
–
–
–
–
–

Construction
Room Interior finish
Corridor interior finish
Corridor walls
Corridor doors
Smoke zone dimensions
Vertical openings
-
Hazardous areas
Smoke control/ barriers
Emergency movement routes
manual fire alarm FD connection
smoke detection and alarm
automatic sprinklers – coverage/QR
Fire Safety Requirements – no choice
– Exit signs
– Evacuation plan/ drills
– HVAC comply 90A
- emergency lighting
- furnishings combustibility
- fire extinguishers comply NFPA 10
Gene Cable (518) 794-7237
Fire and Life Safety Model - Escape
Time
Time to
Detection
Fire
Ignition
Time to
Notify
Time for Smoke To Block Egress Path
Occupants
Fire Development - fire growth curve
Egress
Route
Blocked
Detection
Occupants
Alerted
Occupants
Safely Out
Time Needed To Get Out
Response To
Delay
Prepare
To Travel
Safety
Margin
Gene Cable
(518) 794-7237

Video
ILSM Standards and Policy
Final segment
 But First – the score; ILSMS: YES or NO?

–
–
–
–
–
1.
2.
3.
4.
5.
Self-closer broken
Y: 28 N: 23
Stair pipe penetrations Y: 41 N: 10
Ceiling tiles missing Y: 12 N: 39
Wall missing (trick) Y: 29 N: 22
Electrical Transformer rm door Y: 41 N: 10
The five quiz examples






In my opinion anyway:
1. Even if storage room, I Would not even
evaluate for ILSMS – No
2. Do the ILSM evaluation and likely yes needed
3. No evaluation needed and NO ILSMs
4. (trick) corridor wall not required in the first
place, QR sprinkler and smoke detector in the
open space – Yes Evaluation, but No ILSMs
5. Gave a hint, electrical room, 20,000 F arc
flame potential, yes do evaluation and likely Yes
Accreditation Rules
Situational Decision Rules in EC (trigger)

Immediate Threat to Health or Safety
– Rule: Preliminary Denial of Accreditation

Failure to make sufficient progress on previously
accepted PFIs (LS.01.01.01 EP 2)
– Rule: Accreditation with Follow-up Survey

Failure to develop an acceptable ILSM policy
– Rule: Accreditation with Follow-up Survey

Failure to implement appropriate ILSMs
(LS.01.02.01 EP 4 – 14) Direct or an Indirect
finding – no rule; less serious
– For EP # 4 -14, 5 are “directs”
– Example: Provide additional firefighting equipment – D
Conducts one additional fire drill - ID
Interim Life Safety Measures

Actual standard: “ The Organization protects occupants
during periods when the LSC is not met or during periods
of construction.”

Order of Standards (LS.01.02.01)
– EP 1 & 2: regardless of ILSM policy
– EP 3: must clearly define the ILSM policy including
» Both construction related and non-compliance with
the LSC
» When to implement
» What to do to protect occupants
– EPs 4 – 14 align with policy and implementation
strategies
EP 1 - Fire Watch
 An
organization experiencing a compromising situation (4 out
of 24 hours) must implement a fire watch until the fire alarm
system or sprinkler system has been returned to service or is
stable.
– In many situations, this distinction comes down to whether
an event or activity is scheduled or unscheduled.
 A scheduled
activity would be an event known to and under
the knowledge of and control of organization staff
– a construction project
– servicing or upgrading the fire alarm system or sprinkler
system.
Service Situation
Putting a shield over one smoke detector to prevent
dust/false alarms for more than 4 hours
Fire Watch
Required?
ILSM
Evaluation
Required?
No
Recommended
Rationale: Other features of fire protection are not compromised during the event, such
as additional smoke detectors or sprinkler heads in the affected area.
Covering all smoke detectors during a controlled event, such
as only during the time contractors are working in an
affected area, although after hours, the entire area is
fully operational
No
Yes
Rationale: During a controlled event the organization is managing the deficiency. The
area would be continually monitored, and ILSM should be implemented as per policy.
Shutting off a zone valve to the sprinkler system or disabling
a fire alarm zone for more than 4 hours
● Scheduled event (that is, working on, servicing, or
upgrading fire alarm system or sprinkler system)
Not in all
cases
Yes (emphasis
on occupant
notification)
Rationale: During a controlled event, the organization is managing the deficiency. The
area would be continually monitored, and ILSM would be implemented as per policy.
● Unscheduled event (that is, shutting off a zone valve
to the sprinkler system or disabling a smoke zone for
more than 4 hours in response to a system failure)
Yes
Yes
Fire Watch (NFPA 101 Section 9.7.6)

Can do fire watch for less than 4 hour impairment
Can be normal staffing for small scale impairment

Section A9.7.6;

“involve some special action beyond
normal staffing, such as assigning an additional security
guard(s) to walk the areas affected.”
EP 2 – Alternate Exits

Post signage to ID alternate exits and way to get
there.
EP 3 – The ILSM Policy
» Have one
» Both construction related and non-compliance LSC
» When to implement
EP 3: “The organization has a written interim life safety measure (ILSM)
policy that covers situations when LSC deficiencies cannot be
immediately corrected or during periods of construction.” “The policy
includes criteria for evaluating when and to what extent the
organization follows special measures to compensate for increased life
safety risk.”
EP 3 Policy Example # 1
SUBJECT:
INTERIM LIFE SAFETY POLICY
The XX Medical Center recognizes that construction and/or renovation activities have
the potential to increase the risk of injury to staff, patients and/or visitors. Because of
this potential, a program of risk evaluation and mitigation strategies has been
developed to minimize these risks. The following procedures will be followed during
all construction and/or renovation activities that have this potential.
At the completion of the preliminary design phase and prior to beginning construction or
renovation, an Interim Life Safety Measures, (ILSM), Review Checklist will be
completed by the Construction Projects Manager or his designee.
Identified Life Safety Deficiencies
In addition to construction and renovation activities, interim life safety measures must be
considered whenever there is an identified life safety deficiency. This could occur as
a result of a periodic life safety assessment or as an item identified during a
scheduled hazardous surveillance tour. Whenever a life safety code deficiency is
identified a review will be conducted to determine the need for interim life safety
measures.
CRITIQUE: Covers the two major bases CONCERN: Boxed self in, all defs.
Take OUT
Example # 2
Policy # 6602 Interim Life Safety Measures
It is the policy of XX Memorial Medical Center to assess the need for Interim
Life Safety Measures (ILSM) to ensure the safety of all building occupants
during periods of construction or when significant deficiencies or
impairments compromise the level of life safety protection provided by
building Life Safety Features.
ILSM apply to all personnel, (including construction workers) working in
Health Care, Ambulatory Care Buildings, and any other occupancy
classifications deemed appropriate by the Life Safety Officer or designee.
ILSM must be assessed whenever a significant deficiency is identified or
prior to the start of any construction project where ILSM are required as part
of the Pre-Construction Risk Assessment (PCRA). ILSM shall not be
warranted for incidental short-term deficiencies.
CRITIQUE: Covers the two major bases; does avoid the “all deficiencies”
Concern: Who decides: “significant” and what is “short-term” .
Add IN
Example # 2 addendum
Policy # 6602 Interim Life Safety Measures
(Same policy as Example # 2 with definitions)
II. Definitions:
Incidental short-term deficiencies: Minor transient deficiencies that only effect
local areas, do not pose any systemic risks and will be corrected by the
Maintenance department. Examples include the failure of one corridor
smoke sensor which is flanked by other working sensors, dirty sprinkler
heads and other deficiencies of similar magnitude.
Significant Deficiencies: Life Safety Code deficiencies that pose systemic
risks. Examples include blocking of egress corridors due to
construction, impairments to smoke and/or fire barriers and
impairments to suppression and detection systems greater than 4 hours.
GOOD
Example # 3
Policy # 6602 Interim Life Safety Measures with definitions
It is the policy of XX Memorial Medical Center to assess the need for Interim Life Safety
Measures (ILSM) to ensure the safety of all building occupants during periods of
construction or when significant deficiencies or impairments compromise the level of
life safety protection provided by building Life Safety Features.
ILSM apply to all personnel, (including construction workers) working in Health Care,
Ambulatory Care Buildings, and any other occupancy classifications deemed
appropriate by the Life Safety Officer or designee. ILSM must be assessed whenever a
significant deficiency is identified or prior to the start of any construction project
where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA).
ILSM shall not be warranted for incidental short-term deficiencies.
The surveyor/ evaluator identifying the deficiency determines whether or not it is a
significant or incidental short-term deficiency. The Life Safety Officer should be
consulted in questionable situations and can ultimately overrule .
CRITIQUE: Covers the two major bases; does avoid the “all deficiencies” aspect
Concern: None
Add IN
EP 3 – The ILSM Policy
» Have one
» Both construction related and noncompliance LSC
» When to implement
EP 3 – The ILSM Policy
» What to do to protect occupants –EP 4 – 14
Policy example # 1
EP 3: “The organization has a written interim life safety measure (ILSM)
policy that covers situations when LSC deficiencies cannot be
immediately corrected or during periods of construction.” “The policy
includes criteria for evaluating when and to what extent the
organization follows special measures to compensate for increased life
safety risk.”
Prior to the start of the project, the project details and the
ISLM Review Checklist will be reviewed with the Safety
Officer, an Engineering Services Representative, the XX
Construction Representative and the Contractor
representative. Any additions or revisions to the checklist
will be noted and will be added to the project procedures.

Two matrix checklists
ILSM EP # 8

On Matrix decided to increase hazard self
inspections – crawl space for combustibles

Keep the documentation of those
inspections for 3 years.
– If not available – Indirect finding
Conclusion
Covered ILSM background
 Real world major life safety factors
 The important vulnerabilities of the ILSM
policy
 And some INs and OUTs for a good policy


This presentation will be on the NEHES
Webb site