to main content ILSM - Grouping of Survey-related Plans for Improvement (SPFI) for Assessment | Assisted Living Community | Life Safety LS | The Joint Commission
ILSM - Grouping of Survey-related Plans for Improvement (SPFI) for Assessment

Does an ILSM assessment have to be completed for every Survey-related Plan for Improvement?

Any examples are for illustrative purposes only

An Interim Life Safety Measures (ILSM) assessment must be completed for any Life Safety Code deficiency when it becomes apparent to the organization. 

Survey-related Plans for Improvement (SPFIs)^ are developed when the organization cannot correct a deficiency related to NFPA 101-2012 or NFPA 99-2012 within 60 days of the survey event. This SPFI is the basis for requesting a Time Limited Waiver (TLW). The ILSM assessment must be identified in the SPFI entered into the Statement of Conditions (SOC). The validation documentation must clearly demonstrate that the risks identified are being mitigated. 

^The Survey Related PFI (SPFI) tab is located on the Statement of Conditions page accessed via the organization's secure extranet site.

Manual: Assisted Living Community
Chapter: Life Safety LS
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on March 22, 2022 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
Was this response helpful?

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form

Get Extra Help with Books and E-books

Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.

Stay Informed with Online Education

Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.

Reach Your Safety Goals with eProducts

Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.

Can't Find What You're Looking For?

If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG).

Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. The Joint Commission no longer answers questions submitted by students or vendors. Thank you for your understanding.