POLICY: INTERIM LIFE SAFETY MEASURES
I PURPOSE:
To define a process that evaluates life safety deficiencies and construction dangers and implement appropriate interim measures that compensate for the hazards until they are remedied.
II SCOPE:
This policy applies to all facilities owned or used by All Saints Healthcare System.
III DEFINITIONS
Life Safety Code (LSC): The fire protection guideline published by the National Fire Protection Association (NFPA) as Code #101. Compliance is required of the version of the Code that has been adopted by the three Authorities Having Jurisdiction (AHJ): JCAHO, Wisconsin Department of Health & Family Services (WDHFS), and Center for Medicare Services (CMS)
Interim Life Safety Measures (ILSM): Eleven actions defined in the Environment of Care (EC) standards of The Joint Commission that must be implemented, in part or whole, to compensate for hazards created by life safety code deficiencies or construction projects. Summarized, they include:
1. Exits for staff and construction workers must be free and unobstructed. Personnel must be trained on alternate exits. Construction exits must be inspected daily.
2. Access to Emergency services must be free and unobstructed.
3. Fire alarms & sprinkler systems must be operational. Equivalent systems must be provided in case of impairment and must be inspected/tested monthly.
4. Temporary construction partitions must be smoke tight and made of noncombustible materials.
5. Additional fire fighting equipment must be provided and staff trained.
6. Smoking must be prohibited, including in construction areas.
7. Storage and debris must be kept to the lowest feasible level.
8. Fire drills must be conducted at least twice per quarter per shift.
9. Hazard surveillance must be conducted in construction areas.
10. Staff must be trained on impaired fire safety features.
11. The organization-wide safety education program must promote awareness of the life safety deficiencies, construction hazards and ILSM in use.
IV. POLICY
- All compliance deficiencies to the Life Safety Code must be appropriately compensated for with temporary measures that reduce the degree of fire risk and/or improve the ability of staff to respond to fires or evacuate. Interim measures must be implemented in two situations:
1. When a life safety deficiency is noted and can not be immediately repaired, and
2. Prior to the start of each phase of all construction projects.
B. The specific required interim measure will be determined by evaluating:
1. Person at risk, 5. Sprinkler availability
2. Type and number of hazards, 6. 24 hour staff availability
3. Integrity of compartments, 7. Combustibility load
4. Occupancy type 8. Other appropriate considerations
C. The Evaluation Checklist tool will be used to consistently consider these factors and guide the application of the appropriate ILSM (refer to Exhibit A).
V PROCEDURE
A. The Facility Director is responsible for evaluating the need for interim measures and for coordinating the implementation of the ILSM.
1. This is accomplished by completing the Evaluation Checklist (Exhibit A).
2. Representatives of the Facilities, Maintenance, Safety, Infection Control, and the general contractor (if a construction project) will sign the evaluation.
B. The checklist will be reviewed anytime there is a reduction of life safety features.
C. The requirements of the Evaluation Checklist will be reviewed with the contractors during pre-construction meetings and at least monthly throughout the duration of the project.
D. Compliance with each required action will be monitored weekly and documented by the Facility Department. Exits within the construction areas will be inspected daily by the general contractor foreman.
Exhibit A
EVALUATION CHECKLIST
LIFE SAFETY INTERIM MEASURES
LOCATION OF DEFICIENCIES: CAMPUS:______BLDG: ______
SUMMARY OF DEFICIENCIES:______
______
______
TITLE OF CORRECTIVE WORK: ______
______
A. ACTIONS NEEDED DURING ALL DEFICIENCIES
STAFF NOTIFICATION: Organization-wide safety education programs must be conducted to ensure awareness of any life safety deficiency, construction hazards and all temporary measures required by this checklist. Consultation must be made with the Safety Manager, Infection Control staff, Security, Environmental Service, Employee Health and effected department heads.(JCAHO-ILSM #11)
REQUIRED ACTIONS:
B. ACTIONS NEEDED IS EXIT IS RESTRICTED: APPLICABLE? _____YES _____NO
ALTERNATE EXITS: If any exit or exit access corridor is restricted, even temporarily, to below 48” obstruction-free width: (JCAHO-ILSM #1)
1. An alternative exit route must be designated,
2. Temporary exit route must have signage,
3. Area staff must receive training on the alternative exit,
4. Pathway must be inspected daily to ensure they are unobstructed.
REQUIRED ACTIONS:
C. ACTIONS NEEDED IF FIRE/SMOKE WALL OR FLOOR IS IMPAIRED:
APPLICABLE? _____YES _____NO
ALTERNATE FLOOR/WALL OPTIONS: If deficiencies involve floor opening or any fire, smoke, shaft, corridor or suite wall/door: (JCAHO-ILSM #10)
1. The quantity of combustibles in the area must be reduced;
2. Temporary fire partitions of same rating of wall to be installed when area is not occupied;
3. Staff in the affected area must be trained on alternative procedures
REQUIRED ACTIONS:
D. ACTIONS NEEDED IF DETECTION/SUPPRESSION SYSTEM IMPAIRED:
APPLICABLE? _____YES _____NO
ALTERNATVE ALARM/EXTINGUISH SYSTEMS: If fire alarms, smoke detector, sprinkler or other detection or suppression system is impaired or removed from service: (JCAHO-ILSM #3)
1. If overnight: a temporary, but equivalent system shall be provided, inspected, and weekly tested.
2. If less than overnight: follow established notification safeguards.
REQUIRED ACTIONS:
E. ACTIONS NEEDED IF DEFICIENCIES ARE SERIOUS:
APPLICABLE? _____YES _____NO
The seriousness of a deficiency is based on the following algorithm:
A. Who is at Risk? / Inpatients / 2 ptsOutpatient/Visitor / 1 pt
Staff/Contr / 1 pt
B. How Long will Deficiency Exist? / Under 2 weeks / 0 pt
2-4 weeks / 1 pt
> 4 weeks / 2 pts
C. How Many Impairments? ( see B-D above) / Each Impairment of r Alarm r Sprinkler r Exit r Fire Wall/Floor / 1 pt ea
TOTAL POINTS
IF LESS THAN 6 POINTS, THEN NOT SERIOUS; IF 7 OR MORE POINTS, THEN SERIOUS AND THE FOLLOWING ACTIONS MUST BE IMPLEMENTED:
1. ADDED FIRE EQUIPMENT: Additional fire fighting equipment and training on their use must be provided. (JCAHO-ILSM #5)
REQUIRED ACTIONS:
2. ADDED FIRE DRILLS: Fire drills shall be conducted a minimum of twice per shift per quarter in buildings that have deficiencies or construction projects that last 3 months or longer. (JCAHO-ILSM #8)
REQUIRED ACTIONS:
WHO IS RESPONSIBLE:
F. ACTION NEEDED NEAR EMERGENCY DEPARTMENT:
APPLICABLE? _____YES _____NO
UNOBSTRUCTED ACCESS: Access must be kept free and unobstructed to the Emergency department via both internal and external entry. (JCAHO-ILSM #2)
REQUIRED ACTIONS:
WHO IS RESPONSIBLE:
CONTRACTOR EDUCATION: All contractor and subcontractor workers must be made aware of, and follow organization safety practices. All contractor foremen receive train-the-trainer education on an annual basis on the standard ASHS Contractor Safety Program. Foreman must ensure all of their staff assigned to the job for more than one day must receive the training and pass the ASHS Contractor Safety Test. Smoking is prohibited within 20’ of all construction sites. Smoking permitted in designated smoking areas only. (JCAHO-ILSM #6)
REQUIRED ACTIONS: *Follow education & practice requirements contained in
Contractor Work Practices Policy.
CLEANLINESS: Storage, housekeeping and debris removal policies and procedures must be understood and enforced during the entire project. Flammables and combustible materials within the project area shall be kept at the lowest level necessary for daily operations Refer to the Safety Specifications for the policies and procedures. (JCAHO-ILSM #7)
REQUIRED ACTIONS: *Follow practice requirements contained in Contractor Work
Practices Policy.
INSPECTIONS: Inspections of the building, grounds and equipment in and near the project area must be increased with special attention to construction sites, excavations, storage areas and field offices. (JCAHO-ILSM #9)
REQUIRED ACTIONS: *Follow practice requirements contained in Contractor Work
Practices Policy.
PARTITION SPECIFICATIONS: Temporary construction partitions needed for dust, noise, safety or security protection must be smoke tight and built only of noncombustible or limited combustible materials. (JCAHO-ILSM #4)
If the sprinkler system within the construction area is shutdown for over 24 hours the partition must be 1 hour rated construction.
REQUIRED ACTIONS: *Follow practice requirements contained in Contractor Work
Practices Policy.
*I have evaluated the life safety implications of the stated deficiencies, consulted with persons identified below, and feel the indicated ILSM’s will adequately control the life safety hazards caused by the deficiencies and corrective construction work.
Safety Manager Date:
Infection Control Date:
Employee Health Manager Date:
Environmental Services Mgr. Date:
Security Manager Date:
Department Manager Date:
Department Manager Date:
Department Manager Date:
Facility Director Date