1 We Put Patients First ILSM Interim Life Safety Measures (ILSM) Sukhjit Tom Singh, MHA, MPH Field Director Facilities Operations Regulatory Compliance
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ILSM Interim Life Safety
Measures (ILSM)
Sukhjit Tom Singh, MHA, MPH
Field Director Facilities Operations Regulatory Compliance
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ILSM • What are Interim Life Safety
Measures ? – A proactive risk management program
– Temporary measures implemented when life safety features or systems are compromised
– Extends beyond life safety code requirements
Background & Significance
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ILSM Process
• ILSM Assessment • All Construction and renovation projects • Review scope and impact to life safety • Determine appropriate measures to be
implemented
• Re-Assessment • Change in scope
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ILSM Process Continued
• Monitoring of ILSM Measures • Daily Inspection • Weekly Inspection • Monitoring & Improvement
• Identification and correction of deficiencies
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ILSM ILSM Trends
• Top Conditions Identified Monthly • Fire Extinguishers
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ILSM ILSM Trends Continued
• Progress in Reducing Conditions
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ILSM - Inspections • Is the means of egress free and unobstructed from
construction and adjacent areas?
Corridor Restricted with no ILSM measures
Exit Door Tied/Locked Immediate Threat To Life!
Tape Around Doors
Conflicting Signs
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ILSM - Inspections • Are alternate exit signs and/or directional signage in place?
– All exit signs and arrows need to be photoluminescent.
Exit Sign Directing Occupants to a Blocked Exit
Construction Partition Protruding into Means of Egress without Proper Temporary Exit Signage
Combustibles in
corridor
Appropriate
Directional Signage
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ILSM - Inspections • Are alternate exit signs and/or directional signage in place?
– All exit signs and arrows need to be photoluminescent.
No Storage in the Means of Egress (Corridor, Stairwell & Exit Discharge)
Inside Stairwell
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ILSM - Inspections • Is access to emergency services and for emergency
responders free and unobstructed?
Netting blocking Fire Department access to Fire Department Connection for the Sprinkler System.
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ILSM - Inspections • If the fire detection and/or suppression system in the
effected area(s) is impaired for more than 4 hours in a 24-hour period, is a fire watch in place?
Sprinkler Capped; Does removing the ceiling require a fire watch?
Never Touch Fire Detection Devices
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ILSM - Inspections • All fire detection & suppression system devices free of
obstructions?
Fire alarm pull station obstructed by temporary construction partition.
Fire alarm strobe obstructed by temporary construction partition.
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ILSM - Inspections • Are all separation barriers constructed to acceptable stands
as to material and design and safely separated from all occupied areas?
Compromised 2-hour fire rated wall separating construction site from Stairwell
serving entire building.
Temporary fire stopping pillow improperly installed.
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ILSM - Inspections • Are additional portable fire
extinguishers properly mounted, accessible and inspect?
• Requirements
– Monthly “Visual” Inspection.
– Mounted with handle less than 5 feet from the ground and the bottom of the fire extinguisher greater than 4 inches above the ground.
Best Practice!
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ILSM - Inspections • Is the combustible/flammable load kept to a minimum?
Increased Combustible Load Door Propped; Oxidizer increases fire intensity
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ILSM - Inspections • Are all compressed gas cylinders properly secured and
stored? Improper use of compressed gas cylinder,
significant finding
Unsecured
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ILSM - Inspections • Is the site free of any new life safety
conditions/deficiencies? Missing Sprinkler/Standpipe
System Signage
What floors/areas are
served?
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Fire Safety
ILSM
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ILSM Upon a Fire Alarm Activation, implement the RACE Procedure:
Remove/Rescue anyone in immediate danger Alarm by Shouting Code Red and activate the fire alarm system Confine by closing all doors Evacuate to a safe area of refuge and/or extinguish the fire
Fire Emergency Response
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ILSM When utilizing a Fire Extinguisher, implement the PASS technique:
Pull the pin Aim the nozzle at the base of the fire Squeeze the handle Sweep the extinguishing agent side to side across the base of the fire
Use only for incipient (small) fires
Fire Emergency Response Cont.
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ILSM • Hot Work Permits are issued at the
Fire Safety Office • Advanced Notification • Must be renewed daily if the work
requires additional time • NYC prohibits hot work activity when
the sprinkler system is impaired: • Less than 5 Floors - Notification • 5 or More Floors - Variance
Hot Work Permits
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ILSM Inspection \ Maintenance Permit
Penetration
Approval from Fire Safety, Infection Control & Facilities Operations
Above Ceiling Work Vest
Close-Out of Permit
Above Ceiling Work Permit
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ILSM Causes disruption to the delivery of patient care Operational Impact
Internal Response FDNY Response
Violations and Fines Important: Follow USI Process
Unwarranted Alarms
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Hartford Hospital Fire 1961
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Importance of ILSM
Fire within the Smoke Compartment
Adjacent Smoke Compartment
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ILSM Quiz • Fire Detection & Suppression Systems
Impaired • Possible ILSM: Fire Watch & Emergency
Forces Notification
• Means of Egress Restricted or Rerouted • Possible ILSM: Staff Education &
Re-directional signage
• Fire/Smoke Walls & Doors Compromised • Possible ILSM: Temporary Partitions
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Questions?
? ILSM
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