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ILSM - grouping of SPFIs 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. 

Reference: LS.01.01.01 EP 4 
Last updated on March 29, 2021
Manual: Hospital and Hospital Clinics
Chapter: Life Safety LS

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