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ILSM - Policy Timeframes

Regarding a Life Safety Code deficiency, what is the definition of “immediate” and is an ILSM assessment required for each Survey-related Plan for Improvement (SPFI) which cannot be addressed immediately?

Any examples are for illustrative purposes only. 

The context of "immediate" is to allow for a fire-safe facility, either by correction of the identified Life Safety Code deficiency, or by implementing mitigating activities to compensate for the deficiency. 

The Joint Commission allows the organization to use their professional judgement and their knowledge of their facility's unique circumstances to determine the timeline associated with "immediate." That judgement would determine the timeline on "immediate" based upon the criticality and severity of the identified deficiency. 

An Interim Life Safety Measures (ILSM) assessment must be made for any deficiency when it becomes apparent (immediately) to the organization. Survey-related Plans for Improvement (SPFIs) may be used when the organization cannot complete a deficiency related to NFPA 101-2012 of NFPA 99-2012 within 60 days of the survey event. The ILSM assessment must be identified in the SPFI once entered in the Statement of Conditions (SOC). If ILSMs are implemented, the validation documentation must demonstrate that the risks identified by the SPFIs are being mitigated. 
 
Reference LS.01.01.01 EP 4
Last updated on March 29, 2021
Manual: Critical Access Hospital
Chapter: Life Safety LS

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