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].

ILSMsILSMs

Eugene A. Cable, P.E. Eugene A. Cable, P.E. Life Safety ConsultantsLife Safety Consultants NEHES NFPA LiaisonNEHES NFPA Liaison412 Horse Heaven Road412 Horse Heaven RoadAverill Park, New York 12018 Averill Park, New York 12018 (518) 794-7237 (518) 794-7237 [email protected]@Fairpoint.Net

Introduction Introduction

Background and “Code Creep” Background and “Code Creep”

Real World Life Safety FactorsReal World Life Safety Factors

ILSM Standards and PolicyILSM Standards and Policy

ILSM DefinitionILSM Definition

Special measures taken to compensate for Special measures taken to compensate for increased life safety risk. increased life safety risk.

– ““Code Creep”: When codes and standards are Code Creep”: When codes and standards are enforced beyond their true intent. enforced beyond their true intent.

BackgroundBackground

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 CreepBackground Code Creep George Mills and Joint Commission presenters:George Mills and Joint Commission presenters:

– Try to stop creep by emphasizing your policyTry to stop creep by emphasizing your policy

– ““The ILSM review is driven by your policy” The ILSM review is driven by your policy” – ““An ILSM policy An ILSM policy should be in forceshould be in force during any situation in which a during any situation in which a

LSC violation cannot be immediately corrected” (2011 Essentials)LSC violation cannot be immediately corrected” (2011 Essentials)

Rest of EP #3, 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 policyReason: Easy to just copy the standard into a policy Reason: Ghost standard spreads quicklyReason: Ghost standard spreads quickly

BackgroundBackground

NFPA 101 addresses non-complianceNFPA 101 addresses non-compliance– Section 4.6.4 Time allowed for complianceSection 4.6.4 Time allowed for compliance – Section 4.6.9.1 Conditions for occupancySection 4.6.9.1 Conditions for occupancy

» No serious life safety hazard exists as judged by the AHJ.No serious life safety hazard exists as judged by the AHJ.

– Section 4.6.10.1 Occupied during Section 4.6.10.1 Occupied during construction 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 The Life Safety Code acknowledges that deficiencies occur all the time. deficiencies occur all the time.

Real World Life Safety FactorsReal World Life Safety Factors

Life Safety CodeLife 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 3 X 5 Cards – Quiz

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

Real World Life Safety FactorsReal 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 measuresDifficult to decide appropriate alternative measures

FSES Equivalency methodology outlines THE major FSES Equivalency methodology outlines THE major factors/parameters for life safety.factors/parameters for life safety.

FSES Life Safety FactorsFSES Life Safety Factors Patient mobility/ density/ location/staff ratioPatient mobility/ density/ location/staff ratio

– Called the “occupancy risks”

Building safety parametersBuilding safety parameters– ConstructionConstruction - Hazardous areas- Hazardous areas– Room Interior finishRoom Interior finish - Smoke control/ barriers- Smoke control/ barriers– Corridor interior finish Corridor interior finish - Emergency movement routes- Emergency movement routes– Corridor wallsCorridor walls - manual fire alarm FD connection- manual fire alarm FD connection– Corridor doorsCorridor doors - smoke detection and alarm- smoke detection and alarm– Smoke zone dimensionsSmoke zone dimensions - automatic sprinklers – coverage/QR- automatic sprinklers – coverage/QR– Vertical openingsVertical openings

Fire Safety Requirements – no choiceFire Safety Requirements – no choice– Exit signsExit signs - emergency lighting- emergency lighting– Evacuation plan/ drillsEvacuation plan/ drills - furnishings combustibility- furnishings combustibility– HVAC comply 90AHVAC comply 90A - fire extinguishers comply NFPA 10- fire extinguishers comply NFPA 10

Gene Cable (518) 794-7237Gene Cable (518) 794-7237

Fire and Life Safety Model - Fire and Life Safety Model - EscapeEscapeTime

Time toDetection

Time to Notify Occupants

Time for Smoke To Block Egress Path

OccupantsSafely Out

FireIgnition Detection

Occupants Alerted

EgressRouteBlocked

Time Needed To Get Out

ResponseDelay

ToPrepare

To Travel

SafetyMargin

Fire Development - fire growth curve

Gene Cable(518) 794-7237

Video Video

ILSM Standards and PolicyILSM Standards and Policy

Final segmentFinal segment But First – the score; ILSMS: YES or NO?But First – the score; ILSMS: YES or NO?

– 1. Self-closer broken Y: 28 N: 23 1. Self-closer broken Y: 28 N: 23 – 2. Stair pipe penetrations Y: 41 N: 102. Stair pipe penetrations Y: 41 N: 10– 3. Ceiling tiles missing Y: 12 N: 393. Ceiling tiles missing Y: 12 N: 39– 4. Wall missing (trick) Y: 29 N: 224. Wall missing (trick) Y: 29 N: 22– 5. Electrical Transformer rm door Y: 41 N: 105. Electrical Transformer rm door Y: 41 N: 10

The five quiz examplesThe five quiz examples

In my opinion anyway: In my opinion anyway:

1. Even if storage room, I 1. Even if storage room, I Would not even Would not even evaluate for ILSMS – Noevaluate for ILSMS – No

2. Do the ILSM evaluation and likely yes needed2. Do the ILSM evaluation and likely yes needed 3. No evaluation needed and NO ILSMs3. No evaluation needed and NO ILSMs 4. (trick) corridor wall not required in the first 4. (trick) corridor wall not required in the first

place, QR sprinkler and smoke detector in the open place, QR sprinkler and smoke detector in the open space – Yes Evaluation, but No ILSMsspace – Yes Evaluation, but No ILSMs

5. Gave a hint, electrical room, 20,000 F arc flame 5. Gave a hint, electrical room, 20,000 F arc flame potential, yes do evaluation and likely Yes 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 Failure to implement appropriate ILSMs (LS.01.02.01 EP 4 – 14) Direct or an Indirect (LS.01.02.01 EP 4 – 14) Direct or an Indirect finding – no rule; less serious finding – no rule; less serious – For EP # 4 -14, 5 are “directs” For EP # 4 -14, 5 are “directs”

– Example: Provide additional firefighting equipment – D Example: Provide additional firefighting equipment – D Conducts one additional fire drill - ID 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)Order of Standards (LS.01.02.01)– EP 1 & 2: regardless of ILSM policyEP 1 & 2: regardless of ILSM policy

– EP 3: must clearly define the ILSM policy includingEP 3: must clearly define the ILSM policy including

» Both construction related and non-compliance with Both construction related and non-compliance with the LSCthe LSC

» When to implementWhen to implement

» What to do to protect occupantsWhat to do to protect occupants

– EPs 4 – 14 align with policy and implementation EPs 4 – 14 align with policy and implementation strategiesstrategies

EP 1 - Fire WatchEP 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 SituationService SituationFire WatchFire Watch

Required?Required?

ILSM ILSM

EvaluationEvaluation

Required?Required?Putting a shield over Putting a shield over one one smoke detector to prevent smoke detector to prevent

dust/false alarms for more than 4 hoursdust/false alarms for more than 4 hoursNoNo RecommendedRecommended

RationaleRationale: Other features of fire protection are not compromised during the event, : Other features of fire protection are not compromised during the event,

such as additional smoke detectors or sprinkler heads in the affected area.such as additional smoke detectors or sprinkler heads in the affected area.

Covering Covering all all smoke detectors during a controlled event, such smoke detectors during a controlled event, such

as only during the time contractors are working in an as only during the time contractors are working in an

affected area, although after hours, the entire area is affected area, although after hours, the entire area is

fully operationalfully operational

NoNo YesYes

RationaleRationale:: During a controlled event the organization is managing the deficiency. The During a controlled event the organization is managing the deficiency. The

area would be continually monitored, and ILSM should be implemented as per policy.area would be continually monitored, and ILSM should be implemented as per policy.

Shutting off a zone valve to the sprinkler system or disabling Shutting off a zone valve to the sprinkler system or disabling

a fire alarm zone for more than 4 hoursa fire alarm zone for more than 4 hours

●● Scheduled event (that is, working on, servicing, or Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system)upgrading fire alarm system or sprinkler system)

Not in allNot in all

casescases

Yes (emphasisYes (emphasis

on occupanton occupant

notification)notification)

RationaleRationale: During a controlled event, the organization is managing the defi ciency. : During a controlled event, the organization is managing the defi ciency.

The area would be continually monitored, and ILSM would be implemented as per The area would be continually monitored, and ILSM would be implemented as per

policy.policy.

●●

Unscheduled event (that is, shutting off a zone valve to Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure)than 4 hours in response to a system failure)

YesYes YesYes

Fire Watch (NFPA 101 Section 9.7.6)Fire Watch (NFPA 101 Section 9.7.6)

Can do fire watch for less than 4 hour impairment Can do fire watch for less than 4 hour impairment Can be normal staffing for small scale impairmentCan be normal staffing for small scale impairment

Section A9.7.6; Section A9.7.6; “involve some special action beyond “involve some special action beyond normal staffing, such as assigning an additional security normal staffing, such as assigning an additional security

guard(s) to walk the areas affected.”guard(s) to walk the areas affected.”

EP 2 – Alternate ExitsEP 2 – Alternate Exits Post signage to ID alternate exits and way to get

there.

EP 3 – The ILSM PolicyEP 3 – The ILSM Policy» Have one Have one

» Both construction related and non-compliance LSCBoth construction related and non-compliance LSC

» When to implementWhen 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 # 2Example # 2

Policy # 6602 Interim Life Safety MeasuresIt 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 # 3Example # 3

Policy # 6602 Interim Life Safety Measures with definitionsIt 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 PolicyEP 3 – The ILSM Policy

» Have one » Both construction related and non-

compliance LSC» When to implement

EP 3 – The ILSM PolicyEP 3 – The ILSM Policy» What to do to protect occupants –EP 4 – 14What to do to protect occupants –EP 4 – 14

Policy example # 1Policy 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 checklistsTwo matrix checklists

ILSM EP # 8ILSM EP # 8

On Matrix decided to increase hazard self On Matrix decided to increase hazard self inspections – crawl space for combustiblesinspections – crawl space for combustibles

Keep the documentation of those Keep the documentation of those inspections for 3 years. inspections for 3 years. – If not available – Indirect finding If not available – Indirect finding

ConclusionConclusion

Covered ILSM backgroundCovered ILSM background Real world major life safety factorsReal world major life safety factors The important vulnerabilities of the ILSM The important vulnerabilities of the ILSM

policypolicy And some INs and OUTs for a good policyAnd some INs and OUTs for a good policy

This presentation will be on the NEHES This presentation will be on the NEHES Webb site Webb site