The Life Safety Surveyor
How Should I Prepare for the Life Safety
Surveyor Documentation Session?
Healthcare Engineering Consultants
The LSS Document Review
Documents likely to be reviewed include:
 Fire system detection and extinguishing test documents
 Electrical system test documentation including emergency
generators, battery lights and SEPPS units
 Medical gas and vacuum system test results and new
installation certifications
 Interim life safety measures policy and documentation
 Pre-Construction Risk Assessment (PCRA) policy and
documentation
 Statement of Conditions (SOC), unless already reviewed
during the Preliminary Planning Session
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The Life Safety Surveyor (LSS)
 It is likely that the LSS will arrive with the team on the first or second day, less
likely later in the survey
 The LSS will be scheduled for at least two days “on-site”, with extra days for
>1.5 million square feet and three or more surveyable healthcare occupancy
buildings (could be up to 5 days “on-site”!)
 The LSS will spend several hours on dedicated documentation review, but
much more time on the facility tour
 Other responsibilities assigned to the LSS will depend on the survey team
member preferences and responsibilities – they will probably conduct the
Physical Environment Interview and Emergency Management review
 The other survey team members will also observe life safety issues, but not
as detailed as the LSS – it is not likely that the nurse and physician will request a
ladder and flashlight!
 If the LSS observes deficiencies outside of their defined responsibility
(example: medical records privacy or medication security), they will report it to
the other team members
Healthcare Engineering Consultants
Fire System Tests
Points to Remember:
 Every fire system device must be individually inventoried,
with each test result documented as “PASS” or “FAIL”
 Test records should be sorted by device type, not as a
combination of devices, and placed in a binder that is tabbed
by each device type
 Written test procedures and references to the NFPA
standards should be readily available
 Documentation should be available to indicate the
resolution of all identified deficiencies
 A method should be used to track when fire system tests
are scheduled and when they have been completed, such
as a monitoring grid or “dashboard”
Healthcare Engineering Consultants
Fire System Tests
Fire System Component Test Schedule
Standard Element of Performance
Points to Remember
The chart on the right indicates the
probable order in which the surveyor
will review the documentation – put
the test records in this order, either
in a binder or in folders

 The test interval may vary
(example: flow devices, fire pump
churn tests), depending upon
adoption of the CMS “Categorical
Waivers”
 Be sure to indicate on the
documentation (or chart) the NFPA
code reference for each test, as
required in standard EC.02.03.05,
EP 25
EC.
02.03.05
1
Scoring
Category
Test
Interval
NFPA
Reference
Fire Component Tests
Supervisory switches
C
Q
NFPA 72
2
Tamper switches, flow devices
C
S/A
NFPA 72
3
Duct detectors, door releasing
devices
Smoke and heat detectors, pull
boxes
Audible and visual alarms
C
A
NFPA 72
C
A
NFPA 72
C
A
NFPA 72
A
Q
NFPA 72
6
Off-premises transmission
equipment
Fire pump churn test
C
W
NFPA 25
7
Water tank level alarms
C
S/A
NFPA 25
8
C
M
NFPA 25
C
A
NFPA 25
10
Water tank level alarms (cold
weather only)
Main drain tests on system
risers
Fire department connections
A
Q
NFPA 25
3
4
5
9
11
Fire pumps (flow test)
A
A
NFPA 25
12
Standpipe test
C
5 yr
NFPA 25
13
Kitchen extinguishing systems
A
S/A
NFPA 96
14
A
A
NFPA 2001
C
M
NFPA 10
C
A
NFPA 10
17
Carbon dioxide/ gaseous
extinguishing systems
Portable fire extinguishers
(visual check)
Portable fire extinguishers
(preventive maintenance)
Occupant hoses
C
NFPA 25, 1962
18
Smoke/ fire dampers
C
3 yr–hydro
5 yr–new
6 years
19
HVAC smoke detectors w/
shutdown
Horizontal/ vertical fire doors
A
A
NFPA 90A
C
A
NFPA 80
15
16
20
Healthcare Engineering Consultants
NFPA 80, 105
Fire System Test Descriptions
Supervisory Devices
 Test interval: Quarterly
 Be prepared to explain which devices are considered
“supervisory” (not including tamper switches!)
 Supervisory signals are defined in the 2000 Life Safety
Code in section 9.7.2 as:
“…monitoring shall include, but shall not be limited to,
monitoring of control valves, fire pump power supplies and
running conditions, water tank levels and temperatures, tank
pressure, and air pressure on dry-pipe valves”
 Typically, the surveyor will ask about documented test
results for power off and phase loss conditions for the fire
pump and low air pressure on dry sprinkler systems
Code Reference: NFPA 72, 1999 edition, Table 7.3.2
Healthcare Engineering Consultants
Fire System Test Descriptions
Waterflow Devices
 Test interval: Quarterly, unless the CMS “Categorical
Waiver” has been adopted, which then requires semi-annual
tests
 Time delay documentation on device activation
recommended
 “Categorical Waiver” applies to vane-type and pressure
switch-type waterflow alarm devices
Code References: NFPA 25, 1998 edition, section 2-3.3 without the
waiver; NFPA 25, 2011 edition, sections 5.3 and 8.3 with the waiver
Healthcare Engineering Consultants
Fire System Test Descriptions
Duct Detectors
 Test interval: Annually
 Must be tested to ensure that the device will sample the
airstream
 Tests must be in accordance with the manufacturer’s
instructions
 Physical verification of damper closure and/ or air handler
shutdown must performed (EC.02.03.05, EP19) and is
required by NFPA 90A, 1999 edition, section 4-4.1
 Failure to test and document the damper closure and/ or
air handler shutdown will result in a Direct Impact finding
Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2,
and NFPA 90A
Healthcare Engineering Consultants
Fire System Test Descriptions
Smoke Detectors
 Test interval: Annually; Sensitivity: AHJ
 Must be tested in place to ensure smoke entry into the
sensing chamber and alarm activation
 Tests must be in accordance with the manufacturer’s
instructions, including type of test smoke and/ or aerosol
 Smoke detector sensitivity tests must use a calibrated
test method, manufacturer’s approved instrument, or other
test method acceptable to the AHJ
Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2
Healthcare Engineering Consultants
Fire System Test Descriptions
Off-Premises Transmission Equipment
 Test interval: Quarterly
 Two tests required:
1. Receipt of signal by off-site “responders” (local fire
department) – Joint Commission requirement
2. Receipt of signal by “receiving station” (can be off-site
stations such as ADT, Simplex, etc. or fire department)
within 90 seconds (reference to NFPA 72)
Code References: NFPA 72, 1999 edition, Tables 7-2.2 and 7-3.2
Healthcare Engineering Consultants
Fire System Test Descriptions
Fire Pumps
 Test interval: Annual flow test; weekly churn test
 Weekly churn test unless CMS “Categorical Waiver” is
accepted, which requires a monthly test (electric pumps)
 Churn test must be activated by dropping water pressure
 Electric pump: 10 minute test; Diesel pump: 30 minutes
 Annual flow test should include a graph of test results
Code References: NFPA 25, 1998 edition, sections 5-3.2.1,
3.2.2; with CMS waiver, NFPA 25, 2011 edition
Healthcare Engineering Consultants
5-
Fire System Test Descriptions
Main Drain Test
 Test interval: Annual
 Either test the system low point or all system risers
 Perform the test using the following steps:
1. Record the initial static pressure
2. Open the main drain valve, record residual pressure
3. Slowly close the main drain valve
4. Record the time to return to initial static pressure
 Changes in the return time indicate possible obstructions
Code References: NFPA 25, 1998 edition, sections 9-2.6 and
Appendix A-9.2.6
Healthcare Engineering Consultants
Fire System Test Descriptions
Fire Department Connections
 Test interval: Quarterly
 Perform and document the following checks:
1. Connections and ID signs are visible and accessible
2. Couplings and swivels rotate smoothly
3. Plugs, gaskets and caps are in place and undamaged
4. Check valve is not leaking
5. Automatic drain valve operates properly
 Intended to be outside fire department connections
Code Reference: NFPA 25, 1998 edition, section 9-7.1
Healthcare Engineering Consultants
Fire System Test Descriptions
Standpipe Waterflow Test
 Test interval: Every Five Years
 Perform and document the following checks:
1. Flow the system at the highest design pressure to the
hydraulically most remote or highest hose connection
of each standpipe system
2. Consult the local AHJ for the appropriate test location
Code Reference: NFPA 25, 1998 edition, section 3-3.1.1
Healthcare Engineering Consultants
Fire System Test Descriptions
Kitchen Extinguishing Systems
 Test interval: Semi-annually
 Perform and document the following checks:
1. Inspect the extinguishing system and hoods
2. Test all actuation components (pull stations, detectors,
dampers, mechanical and electrical devices, etc.)
3. Replace fusible links and sprinkler heads annually
4. Service and/ or replace detection according to
manufacturer recommendations
 Discharge of the system is not required
Code Reference: NFPA 96, 1998 edition, section 8-2
Healthcare Engineering Consultants
Fire System Test Descriptions
Gaseous Extinguishing Systems
 Test interval: Annual
 Perform and document the following checks:
1. Inspection and tests (4-1)
2. Clean agent containers (4-2)
3. System hose inspection (1-year), test (5-years) (4-3)
4. System maintenance (4-5)
5. Training of staff who inspect (4-6)
 Discharge of the system is not required
Code Reference: NFPA 2001, 1996 edition, section 4-1
Healthcare Engineering Consultants
Fire System Test Descriptions
Portable Fire Extinguishers
 Test intervals: Monthly, Annual and 6-Year
 Monthly checks require the following:
1. Proper location, no restriction to access or visibility
2. Instructions for use legible and seals/ indicators OK
3. Fullness determined by “hefting” or weighing
4. Evidence of physical damage and gauge reading
5. Documentation with date/ month/ year/ initials
 Annual preventive maintenance required
 6-Year extinguisher recharge
Code Reference: NFPA 10, 1998 edition, sections 4-3 and 4-4
Healthcare Engineering Consultants
Fire System Test Descriptions
Smoke and Fire Dampers
 Test intervals: Initially, 1-year and 6 years thereafter
 All smoke and fire dampers must be tested initially and
one year after installation
 Re-testing is every four years except 6 years for hospitals
 Inaccessible dampers should be placed on a PFI with a
6-year timeframe for re-evaluation (document ILSM!)
 The 1-year test after installation only applies to dampers
installed after January 1, 2008
Code References: NFPA 80, 2007 edition, section 19.4.1.1; NFPA
105, 2007 edition, section 6.5.2
Healthcare Engineering Consultants
Fire System Test Descriptions
Sliding and Rolling Fire Doors
 Test interval: Annual
 Test must include proper operation and full closure
 Re-setting the release mechanism must be done
according to manufacturer specifications
 Fusible links and other release devices must not be
painted or prevented from operating by sealing gaps with
intumescent materials
Code Reference: NFPA 80, 1999 edition, section 15-2.4
Healthcare Engineering Consultants
Fire System Test Monitoring
Best Practice for Monitoring Compliance
Regulatory Compliance Dashboard for Fire System Tests
Description
JAN
Supervisory
Devices
Tamper
Switches
Water Flow
Devices
Duct Detectors
1/15
X
X
X
1/15
X
X
X
1/15
X
X
X
Door Releasing
Devices
Smoke
Detectors
Pull Boxes
FEB
MAR
APR
AUG
SEP
OCT
NOV
DEC
W
W
W
X
X
X
X
X
X
X
1/18
X
Visual Alarms
X
Kitchen
Systems
JUL
X
X
Fire Pump Flow
Test
Water Tank
Level Alarms
Main Drain
Riser Test
Fire Dept.
Connections
Standpipe Test
JUN
1/22
Audible Alarms
Signal Time to
FD
Fire Pump
Churn Test
MAY
1/6
4, 11
25
X
W
W
W
X
W
W
W
X
W
W
X
N/A
X
X
X
X
1/12
X
X
5 yr
X
X
Healthcare Engineering Consultants
Comments
Fire System Test Monitoring
Regulatory Compliance Dashboard for Fire System Tests (continued)
Description
CO2/ Gaseous
Systems
Portable
Extinguishers
Portable
Extinguishers
Occupant
Hoses
JAN
APR
MAY JUN JUL AUG SEP OCT
NOV
DEC
X
X
Comments
X
1/23
X
X
X
X
X
X
X
X
X
X
X
3 yr
Smoke/ Fire
Dampers
HVAC
Shutdown
Horiz/ Vertical
Fire Doors
FEB MAR
X
6 yr
1/25
X
X
Key to dashboard symbols:
X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required
A/R – Indicates that action is required when applicable
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Healthcare Engineering Consultants
Emergency Power Systems
EC.02.05.07: Emergency Generators
 Perform and document weekly generator visual checks
Code reference: NFPA 110, 2005 edition, section 8.4.1
 Perform and document monthly generator tests with at least
30% of the rated load for 30 minutes
 Document that all automatic transfer switches are exercised
monthly
 Conduct 2-hour annual load bank tests if the 30% load is not
achieved and manifold temperatures are not sufficient
 If the CMS “Categorical Waiver” is adopted by the hospital,
then the 2010 edition of NFPA 110 will require a 1.5 hour annual
load bank test with a 50% load for 30 minutes, and a 75% load
for 60 minutes
Healthcare Engineering Consultants
Emergency Power Systems
EC.02.05.07: Emergency Generators
 Combining the annual and trienniel tests can be performed by starting
the load at 30% of nameplate for the first 30 minutes of the test, then
continuing with: 50% of load for 30 minutes; 75% load for 60 minutes,
and; any load greater than 30% for the remaining 2 hours
Note: If the CMS “Categorical Waiver” is adopted, then the combined
tests require a 50% load for 30 minutes, a 75% load for 1.5 hours and
any load greater than 30% for the remaining 2.5 hours
 Document the static or dynamic 4-hour trienniel test for all generators
 Test fuel oil quality annually per ASTM D-975, unless fuel is
consumed from the entire tank over the course of 12 months
Code Reference: NFPA 110, 2005 edition, section 8.3.8
 Utilize “Interim Emergency Power Measures” (IEPM) when necessary
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Emergency Power Systems
EC.02.05.07: Emergency Battery Lights
 Required in all anesthetizing locations (NFPA 70: 517.63 )
“administration of nonflammable inhalation anesthetic agents
in the course of examination or treatment”
Note: Grandfathering usually permitted in existing OR’s w/o lights
 Required in “Level 1 or Level 2 EPS equipment locations”, which is
normally interpreted as transfer switch locations (NFPA 110: 7.3.1)
 Required in some business occupancies for egress lighting where
emergency power is not required or not available (NFPA 101: 7.9.1.1)
 Monthly 30-second push-to-test and annual 90-minute discharge test
required for all battery installations, whether for task or egress lighting
 Annual battery replacement is acceptable in lieu of 90-minute discharge
test, but 10% of lights must be tested for 90 minutes annually, even if the
batteries are changed
Healthcare Engineering Consultants
Emergency Power Systems
EC.02.05.07: Stored Emergency Power Supply Systems
(SEPSS)
 Standard applies to Level 1 systems (NFPA 111: 4.5.1)
Level 1: “failure of the equipment to perform could result in
loss of human life or serious injuries”
 Testing requires:
1. Quarterly functional test (5 minutes or class specification)
2. Annual full-load test for 60% of SEPSS class duration
Note 1: NFPA 111 requires a monthly inspection, quarterly functional test and
annual full load test for full class duration for Level 1 systems
Note 2: The Joint Commission references exit lighting, life support ventilation, fire
detection and alarm systems, and public communications systems as Level 1
systems, but most are not SEPSS systems, since they are backed up with
emergency generators; non-SEPSS UPS systems should be tested per
manufacturer specifications
Healthcare Engineering Consultants
The LSS Documentation Review
EC.02.05.09: Medical Gas and Vacuum Systems

Medical gas and vacuum system preventive maintenance
program is required (facility must define PM) and must include:
- Bulk medical gas and vacuum system components and source valve
- Master signal panels and area alarms
- Automatic pressure switches and shutoff valves
- Flexible connectors and outlets
Healthcare Engineering Consultants
The LSS Documentation Review
EC.02.05.09: Medical Gas and Vacuum Systems

Testing per NFPA 99 is required for new installation,
modification or repair (cross-connections, purity, pressure)
 Main supply valves and area shut-off valves must be
accessible and clearly labeled
 Utilize “Interim Medical Gas Measures” (IMGM) when
necessary
Note: Significant changes for testing have been included in NFPA
99, the 2012 edition, but it has not yet been adopted by CMS or
the Joint Commission, except for the “Categorical Waiver” tht
permits one master alarm monitor location to be a computer
Healthcare Engineering Consultants
The LSS Documentation Review
EC.02.05.09: Medical Gas and Vacuum Systems
 Certification of installers and verifiers per ASSE 6000 series is
required
 Medical air quality must meet NFPA 99 requirements below:
Parameter
Limit Value
Pressure dew point
39 degrees F
Carbon monoxide
10 ppm
Carbon dioxide
500 ppm
Gaseous hydrocarbons
25 ppm (as methane)
Halogenated hydrocarbons
2 ppm
Healthcare Engineering Consultants
The LSS Documentation Review
Medical Gas and Vacuum System PM Recommendations
Component Description
Note 1: The recommendations
provided in the chart to the right
are from NFPA 99, the 2005
edition, Appendix C, section 5.2.
Tests that are required due to
new system installations,
renovations or repair are listed in
Chapter 5 of NFPA 99
Note 2: Significant changes for
medical gas system tests have
been added to NFPA 99, the
2012 edition, but have not yet
been adopted by either CMS or
the Joint Commission, except for
the single master alarm panel
“Categorical Waiver”
Recommended Test Frequency
Gas cylinder manifold pressure
Daily
Gas cylinder manifold changeover signal
Daily
Liquid cylinder manifold pressure
Daily
Liquid cylinder manifold changeover signal
Daily
Liquid cylinder reserve/ in-use signal
Annually
Bulk liquid system contents gauge
Daily
Bulk system pressure gauges
“Regularly” (weekly)
Bulk system master signal
“Periodically” (monthly)
Main line vacuum system gauge
Daily
Medical air intake location
Quarterly
Medical air pressure gauge
Annually
Medical air high level water sensor
Annually
Medical air receiver drain
Daily
Medical compressed air alarms
Annually
Medical air compressors/ vacuum pumps
Per manufacturer specifications
Dew point sensor/ CO monitor
Annually
Warning system components
Annually
Audible/ visual alarms
Monthly
Shut-off valve leak test
“Periodically” (annually)
Outlet leakage and flow
“Periodically” (annually)
Medical air purity
As determined by facility
Healthcare Engineering Consultants
The LSS Documentation Review
Interim Utility System Measures
Interim Utility System Measures
Best Practice!
Project Number: _________________
Affected System: Fire System: _____
Date: ____________________
Emergency Power _____
Medical Gas: _____
Description of Project: ______________________________________________________
Strongly recommended to
document that interim
measures have been
implemented to compensate
for utility systems that are
taken out of service
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Interim Measures Required:
_____ Affected staff notified
Comments: ______________________________________
_____ Additional Equipment Required Specify: _________________________________
_____ Back-up Procedures in Place Specify: ___________________________________
_____ Emergency Procedures Reviewed Comments: ____________________________
_____ Other: ______________________________________________________________
_____ Other: ______________________________________________________________
_____ Other: ______________________________________________________________
Additional Comments: ______________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Date Project Completed: ___________________ Reviewed By: ____________________
Healthcare Engineering Consultants
Interim Life Safety Measures
Interim Life Safety Measures Requirement
Standard LS.01.02.01 from the Joint Commission
Accreditation Manual:
“The hospital protects occupants during periods
when the Life Safety Code is not met or during
periods of construction”
Healthcare Engineering Consultants
Interim Life Safety Measures
The Interim Life Safety Measures Process
Includes the Following Steps:
1. Is an ILSM evaluation required?
Y or N
2. If Yes, does the ILSM evaluation require the
implementation of ILSM?
Y or N
3. If Yes, which interim measures apply?
4. Implement and document the required measures
Note: An interim life safety measures policy must be
written and address each of the four steps listed
above
Healthcare Engineering Consultants
Interim Life Safety Measures
Step 1: Is an ILSM evaluation required?
The need for an interim life safety measure
evaluation is normally required whenever there is a
life safety deficiency that is found, or renovation or
construction activities create life safety deficiencies.
 Be sure to do an ILSM evaluation for PFI’s!
 Include in the ILSM policy “exclusions” for
evaluations, such as “routine work orders” or
“superficial projects”
Healthcare Engineering Consultants
Interim Life Safety Measures
Example Interim Life Safety Measures Policy
Purpose
Interim life safety measures
evaluation exception for
“routine work orders or
superficial projects that do
not impact life safety”
The purpose of this interim life safety measures (ILSM) policy is to address situations
during periods of construction or renovation, or whenever Life Safety deficiencies exist
and cannot be immediately corrected, so that an equivalent level of Life Safety is
maintained. This policy also includes criteria for evaluating when and to what extent the
hospital follows special, temporary measures to compensate for increased life safety
risk.
Policy
This policy provides information and guidelines for evaluating and implementing interim
life safety measures during times when a Life Safety deficiency is present due to
construction or whenever an existing building deficiency is identified.
Procedure
When the hospital identifies Life Safety deficiencies during surveillance rounds, during
periods of construction or renovation, or through other means, and the deficiency
cannot be immediately corrected, the hospital performs an analysis to determine
whether the implementation of interim life safety measures is necessary.
This analysis is documented using the Interim Life Safety Applicability Form (ILSAF)
attached to Appendix A of this policy. Completion of the ILSAF form is not required for
routine work orders, or superficial projects that do not impact life safety in the hospital.
If the completion of the ILSAF indicates that interim life safety measures are not
required, then the completed form is maintained in a document file for reference
purposes. If the ILSAF indicates that interim life safety measures are required to be
implemented, then the Interim Life Safety Measures Chart (ILSMC) form is completed
(refer to Appendix B) to determine which interim measures must be implemented and
documented.
The ILSMC form should be completed by referring to the following “Typical Triggers” for
each of the possible interim measures listed below. Note: The following list of “Typical
Triggers” are suggestions only and may be revised on the ILSAF form based on the
judgment of hospital personnel.
Measure 1: Notify the fire department, and initiate and document a fire watch.
Typical Trigger Criteria: When the fire alarm or sprinkler system is out of service for
more than 4 hours in a 24-hour period in an occupied building, as defined by the fire
watch decision grid in Appendix C.
Measure 2: Inspect exits in affected areas on a daily basis and document the
inspection.
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Interim Life Safety Measures
Step 2: Are interim life safety measures necessary,
based on the evaluation?
Interim life safety measure “trigger points” include the following:

Egress is compromised, and alternative exits are necessary

Compartmentation is breached,and is considered serious

Part or all of the fire detection or extinguishing system has been
taken out of service

“Hot Work” is being performed

Large quantities of combustible materials are present

Other conditions determined by the organization
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Interim Life Safety Measures
Appendix A - Interim Life Safety Applicability Form
Description of Project or Deficiency: _________________________________________
________________________________________________________________________
Location: ________________________________________________________________
Check which “triggers” (if
any) apply for the project
Add other “triggers, as
desired
If none of the “triggers”
are marked “Yes”, then no
additional action is
required
Instructions: Determine whether any of the “ILSM Triggers” listed in the chart below apply to
or will occur during this project.
Description of ILSM Trigger
Applicable?
Hot work
Y
N
Blocked exit
Y
N
Alternate egress
Y
N
Excessive combustible materials
Y
N
Removal of part or all of the fire detection system
Y
N
Removal of part or all of the extinguishing system
Y
N
Significant breach of smoke or fire wall
Y
N
Significant breach of smoke or fire door
Y
N
Y
N
Y
N
Y
N
If one or more of the ILSM triggers listed above are marked “Yes”, then interim life safety
measures apply and must be evaluated using Appendix B, Interim Life Safety Measures Chart
______ ILSM measures do not apply
_____________________________
Signed
______ ILSM measures do apply
_________________________
Title
Healthcare Engineering Consultants
______________
Date
Interim Life Safety Measures
Step 3: Which interim life safety measures
apply?
The use of an ILSM “applicability matrix” that
helps to determine which interim measures
apply is helpful. The matrix can either be
“pre-filled” for specific conditions or left blank
until the evaluation process occurs. The ILSM
policy should describe how the interim
measures are selected, based on criteria
developed by the hospital
Healthcare Engineering Consultants
Interim Life Safety Measures
Possible Interim Life Safety Measures Include:
 Fire watch
 Alternative exit signage
 Daily inspection of exits
 Temporary, but equivalent fire alarm and detection systems
 Additional fire fighting equipment
 Temporary, smoke-tight, noncombustible partitions
 Increased surveillance of buildings, grounds and equipment
 Storage, housekeeping and debris removal practices
 Additional staff training for staff who use fire equipment
Healthcare Engineering Consultants
Interim Life Safety Measures
Possible Interim Life Safety Measures Include
(continued):
 Additional fire drills
 Inspect and test temporary systems monthly
 Additional staff training related to the interim measures
 Additional training to compensate for impaired fire or building
features
Note: Implementation of any or all of the interim life safety
measures noted in the list above are based on criteria
developed by the hospital and should be listed in the hospital
interim life safety measures policy
Healthcare Engineering Consultants
Interim Life Safety Measures (ILSM)
X
Breach
compartmentation
X
X
X
X
Impair fire detection,
alarm, suppression
X
Hot work
Large quantities of
combustibles
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Healthcare Engineering Consultants
X
Other
X
X
Fire watch
X
Fire drills
Prohibit smoking
Surveillance
X
Staff training
Compromise egress
Reduce combust.
Fire equipment
Barriers
Deficiency
Operational LS
Measure
Notify Fire Dept
Interim
Ensuring Egress
Applicability Grid Example for Interim Life Safety Measures
Interim Life Safety Measures
Example for Interim Life Safety Measures Chart
Appendix B - Interim Life Safety Measures Chart
Description of Project or Deficiency: _________________________________________
________________________________________________________________________
One or more of the interim measures
listed on the chart may be selected,
based on the scope of the project
and the type of deficiency that exists
Location: ________________________________________________________________
Instructions: Based on the project or deficiency described above, determine and document
which of the following interim life safety measures apply in the chart below.
Description of Interim Measure
Applicable?
Fire watch (see Appendix C)
Y
N
Signage signifying alternative exits
Y
N
Daily inspections in affected area
Y
N
Temporary and equivalent fire alarm and detection systems
Y
N
Additional portable fire extinguishers
Y
N
Temporary construction partitions (non- or limited
combustibility)
Increased surveillance of buildings, grounds or equipment
Y
N
Y
N
Additional storage, housekeeping and debris removal
Y
N
Additional staff training for portable fire extinguishers
Y
N
Additional fire drills
Y
N
Monthly tests and inspections of temporary systems
Y
N
Additional staff training for construction hazards, temporary
measures
Additional staff training for impaired fire safety features
Y
N
Y
N
Additional comments related to required measures: ____________________________
______________________________________________________________________
_____________________________
Signed
_________________________
Title
Healthcare Engineering Consultants
______________
Date
Interim Life Safety Measures
Step 4: Implement and document the
required measures
Whichever interim measures are selected
must be implemented and documented
Remember: Failure to implement or
document interim life safety measures, when
required, can result Contingent
Accreditation from the Joint Commission!
Healthcare Engineering Consultants
Interim Life Safety Measures
Healthcare Engineering Consultants
Fire Watch Requirements
LS.01.02.01: EP 1
“The hospital notifies the fire department (or other
emergency response group) and initiates 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. Notification and fire watch times
are documented”
Question: What constitutes when “a fire alarm or
sprinkler system is out of service”?
Healthcare Engineering Consultants
Fire Watch “Decision Grid”
Appendix C – Fire Watch Decision Grid
Description of Project or Deficiency: _________________________________________
The requirement for a
fire watch is
determined by the
hospital staff. NFPA
101, section A.9.6.1.6
states: “it is not the
intent of the Code to
require notification of
the AHJ for a single
non-operating device
or appliance”
________________________________________________________________________
Location of Project or Deficiency: ____________________________________________
Fire Watch Notification:
______ Fire Department
______ Insurance Company
______ Other Responders
______ Internal Hospital Staff
______ Other
Instructions: Based on the “Out of Service” description listed in the chart below, the
requirement for a fire watch is indicated. Circle each “Yes” below, as applicable.
Description of Fire Alarm or Sprinkler System “Out of
Fire Watch Required?
Service” Condition
Multiple fire alarm or sprinkler system components out-ofNo
service for less than 4 hours in a 24-hour period
Fewer than 6 smoke detectors in the same area out-ofNo
service for more than 4 hours in a 24-hour period
Extinguishing system in less than a single smoke compartNo
ment out-of-service for more than 4 hours in a 24-hour period
Fire alarm system in “bypass” mode due to testing
No
More than 5 smoke detectors in the same area out-of-service
for more than 4 hours in a 24-hour period
Extinguishing system in more than a single smoke compartment out-of-service for more than 4 hours in a 24-hour period
Any combination of fire detection and extinguishing devices
out of service > 4 hours in a 24-hour period at the same time
Failure of the fire alarm annunciator panel (any time period)
Yes
Failure of the entire fire detection system (any time period)
Yes
Failure of the entire extinguishing system (any time period)
Yes
Failure of the fire pump (any time period)
Yes
_____________________________
Signed
Yes
Yes
Yes
Y
N
Y
N
_________________________
Title
Healthcare Engineering Consultants
______________
Date
Functional Environment
Issue: Pre-Construction Risk Assessment (PCRA)
Biggest Pitfall: Only ICRA and ILSM are evaluated
Best Practice: Include all seven of the items listed
below in the PCRA evaluation
● Noise
● Emergency procedures
● Vibration
● Utility failures
● Air quality
● Interim life safety measures
● Infection control
Healthcare Engineering Consultants
Infection Control Risk Assessment
(ICRA) – Best Practice Grid
Risk Criteria for Infection Control
Patient
Risk
Construction
Type
Type A
Type B
Type C
Type D
Group 1 (lowest)
I
II
II
III
Group 2 (medium)
I
II
III
IV
Group 3 (medium high)
II
III
III
IV
Group 4 (highest)
III
IV
IV
IV
Healthcare Engineering Consultants
Functional Environment
Issue: Documentation of PCRA
Achieving Compliance:
• Evaluate measures to reduce risk and minimize the
impact of the construction activities
• Perform daily monitoring in all construction areas
• Use a monitoring checklist
• Post required permits, such as hot work, ICRA,
above-the-ceiling work, ILSM, etc. on door entrance
to construction area
Healthcare Engineering Consultants
Functional Environment
Issue: Pre-Construction Risk Assessment (PCRA)
Best Practice: Include MCRA changes during the project
Pre-Construction Risk Assessment Timeline Chart
Project number: __________________________
Date: _____________________
Completed by: ____________________________
PCRA Category
Week
1
Week
2
Week
3
Week
4
Week
5
Week
6
Week
7
Week
8
Noise
Vibration
Air Quality
Infection Control
Risk Assessment
(ICRA)
Interim Life Safety
Measures (ILSM)
Emergency
Procedures
Utility Failures
Healthcare Engineering Consultants
Week
9
Week
10
Comments
The Life Safety Surveyor Document Review
Questions?
Healthcare Engineering Consultants