ILSM - grouping of SPFIs for assessment

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

An Interim Life Safety Measures (ILSM) assessment must be made for any deficiency when it becomes apparent to the organization. Survey-related Plans for Improvement (SPFIs) may be used when the organization cannot completed a deficiency related to NFPA 101-2012 of NFPA 99-2012 within 60 days of the survey event.. The ILSM assessment must be identified 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. 
Last updated on March 13, 2018
Manual: Critical Access Hospital
Chapter: Life Safety LS

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