Standards FAQ Details | Joint Commission
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Friday 5:29 CST, July 14, 2017

Standards FAQ Details

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Life Safety (LS) (Nursing Care Center / Nursing Care Center)


ILSM - Policy Scope
Publish | January 01, 0001
What must an Interim Life Safety Measure policy contain?

In order to evaluate and implement an effective plan for Life Safety code deficiency mitigation, an Interim Life Safety Measure policy must consist of the following:
  • State that the process is applicable to both construction related situations, and situations of non-compliance with the Life Safety Code.
  • State circumstances that would require ILSM assessment, to include a statement that at all Statement of Condition, Plans for Improvement (PFI’s) are to be assessed for ILSM.
  • Describe how the organization will respond to situations described in LS.01.02.01.
  • Describe how occupants are to be protected by using the available menu of interim life safety measures described in LS.01.02.01, as applicable to the situation.
  • Describe the ILSM assessment process, to include an assessment tool to document which measure(s) will be implemented, or no ILSM needed if that is the assessment result.
  • Describe the ILSM implementation process, to be effective throughout the duration of the deficiency(s), and to include an implementation tool to document each implemented ILSM for the duration of its application. [LS.01.02.01]

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