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ILSMs Eugene A. Cable, P.E. Life Safety Consultants NEHES NFPA Liaison 412 Horse Heaven Road Averill Park, New York 12018 (518) 794-7237

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Presentation on theme: "ILSMs Eugene A. Cable, P.E. Life Safety Consultants NEHES NFPA Liaison 412 Horse Heaven Road Averill Park, New York 12018 (518) 794-7237"— Presentation transcript:

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2 ILSMs Eugene A. Cable, P.E. Life Safety Consultants NEHES NFPA Liaison 412 Horse Heaven Road Averill Park, New York (518)

3 Introduction Background and Code Creep Background and Code Creep Real World Life Safety Factors Real World Life Safety Factors ILSM Standards and Policy ILSM Standards and Policy

4 ILSM Definition Special measures taken to compensate for increased life safety risk. Special measures taken to compensate for increased life safety risk. –Code Creep: When codes and standards are enforced beyond their true intent.

5 Background 1996 In the Beginning... By 2004, TJC standard EC.5.50 – – The organization develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Code®. – –EP 1. Each organization develops a policy for using interim life safety measures (ILSMs). 2012, TJC standard LS – –EP 3. The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction

6 Background Code Creep George Mills and Joint Commission presenters: George Mills and Joint Commission presenters: – Try to stop creep by emphasizing your policy –The ILSM review is driven by your policy – An ILSM policy should be in force during any situation in which a LSC violation cannot be immediately corrected (2011 Essentials) Rest of EP #3, Rest of EP #3, The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk. Reason: Easy to just copy the standard into a policy Reason: Easy to just copy the standard into a policy Reason: Ghost standard spreads quickly Reason: Ghost standard spreads quickly

7 Background NFPA 101 addresses non-compliance NFPA 101 addresses non-compliance –Section Time allowed for compliance –Section Conditions for occupancy »No serious life safety hazard exists as judged by the AHJ. –Section Occupied during construction » »Buildings... shall be permitted to be occupied during construction, repair,… only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. The Life Safety Code acknowledges that deficiencies occur all the time. The Life Safety Code acknowledges that deficiencies occur all the time.

8 Real World Life Safety Factors Life Safety Code Redundant requirements Total Concept (Section ) Multiple Safeguards - Prevent Ignition - Detection of Fire - Inhibit fire growth - Confinement of fire and smoke - Extinguishment of fire - Fire Dept actions - Staff action – refuge - Staff action - evacuate

9 Unattended patient bunches up linen on patient bed and slips hand under the pile Series of failures

10 Multiple Safeguards: - Prevent Ignition - Detection of Fire - Inhibit fire growth - Confinement of fire and smoke - Extinguishment of fire - Fire Dept actions - Staff action – refuge - Staff action - evacuate

11 3 X 5 Cards – Quiz

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17 Real World Life Safety Factors ILSM is really an effort at temporary equivalency, to introduce a non-required safety element to make up for one that is required but missing. Difficult to decide appropriate alternative measures Difficult to decide appropriate alternative measures FSES Equivalency methodology outlines THE major factors/parameters for life safety. FSES Equivalency methodology outlines THE major factors/parameters for life safety.

18 FSES Life Safety Factors Patient mobility/ density/ location/staff ratio Patient mobility/ density/ location/staff ratio – –Called the occupancy risks Building safety parameters Building safety parameters –Construction- Hazardous areas –Room Interior finish- Smoke control/ barriers –Corridor interior finish - Emergency movement routes –Corridor walls- manual fire alarm FD connection –Corridor doors- smoke detection and alarm –Smoke zone dimensions- automatic sprinklers – coverage/QR –Vertical openings Fire Safety Requirements – no choice Fire Safety Requirements – no choice –Exit signs- emergency lighting –Evacuation plan/ drills- furnishings combustibility –HVAC comply 90A- fire extinguishers comply NFPA 10 Gene Cable (518)

19 Fire and Life Safety Model - Escape Time Time to Detection Time to Notify Occupants Time for Smoke To Block Egress Path Occupants Safely Out Fire Ignition Detection Occupants Alerted Egress Route Blocked Time Needed To Get Out Response Delay To Prepare To Travel Safety Margin Fire Development - fire growth curve Gene Cable (518)

20 Video Video

21 ILSM Standards and Policy Final segment Final segment But First – the score; ILSMS: YES or NO? But First – the score; ILSMS: YES or NO? –1. Self-closer broken Y: 28 N: 23 –2. Stair pipe penetrations Y: 41 N: 10 –3. Ceiling tiles missing Y: 12 N: 39 –4. Wall missing (trick) Y: 29 N: 22 –5. Electrical Transformer rm door Y: 41 N: 10

22 The five quiz examples In my opinion anyway: In my opinion anyway: 1. Even if storage room, I Would not even evaluate for ILSMS – No 1. Even if storage room, I Would not even evaluate for ILSMS – No 2. Do the ILSM evaluation and likely yes needed 2. Do the ILSM evaluation and likely yes needed 3. No evaluation needed and NO ILSMs 3. No evaluation needed and NO ILSMs 4. (trick) corridor wall not required in the first place, QR sprinkler and smoke detector in the open space – Yes Evaluation, but No ILSMs 4. (trick) corridor wall not required in the first place, QR sprinkler and smoke detector in the open space – Yes Evaluation, but No ILSMs 5. Gave a hint, electrical room, 20,000 F arc flame potential, yes do evaluation and likely Yes 5. Gave a hint, electrical room, 20,000 F arc flame potential, yes do evaluation and likely Yes

23 Accreditation Rules Situational Decision Rules in EC (trigger) Immediate Threat to Health or Safety – –Rule: Preliminary Denial of Accreditation Failure to make sufficient progress on previously accepted PFIs (LS EP 2) – –Rule: Accreditation with Follow-up Survey Failure to develop an acceptable ILSM policy – –Rule: Accreditation with Follow-up Survey

24 Failure to implement appropriate ILSMs (LS EP 4 – 14) Direct or an Indirect finding – no rule; less serious Failure to implement appropriate ILSMs (LS EP 4 – 14) Direct or an Indirect finding – no rule; less serious –For EP # 4 -14, 5 are directs –Example: Provide additional firefighting equipment – D Conducts one additional fire drill - ID

25 Interim Life Safety Measures Actual standard: The Organization protects occupants during periods when the LSC is not met or during periods of construction. Order of Standards (LS ) Order of Standards (LS ) –EP 1 & 2: regardless of ILSM policy –EP 3: must clearly define the ILSM policy including »Both construction related and non-compliance with the LSC »When to implement »What to do to protect occupants –EPs 4 – 14 align with policy and implementation strategies

26 EP 1 - Fire Watch An organization experiencing a compromising situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable. – –In many situations, this distinction comes down to whether an event or activity is scheduled or unscheduled. A scheduled activity would be an event known to and under the knowledge of and control of organization staff – –a construction project – –servicing or upgrading the fire alarm system or sprinkler system.

27 Service Situation Fire Watch Required? ILSM Evaluation Required? Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours NoRecommended Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area. Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational NoYes Rationale: During a controlled event the organization is managing the deficiency. The area would be continually monitored, and ILSM should be implemented as per policy. Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system) Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system) Not in all cases Yes (emphasis on occupant notification) Rationale: During a controlled event, the organization is managing the defi­ciency. The area would be continually monitored, and ILSM would be implemented as per policy. Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure) Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure) YesYes

28 Fire Watch (NFPA 101 Section 9.7.6) Can do fire watch for less than 4 hour impairment Can do fire watch for less than 4 hour impairment Can be normal staffing for small scale impairment Can be normal staffing for small scale impairment Section A9.7.6; involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. Section A9.7.6; involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected.

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31 EP 2 – Alternate Exits Post signage to ID alternate exits and way to get there.

32 EP 3 – The ILSM Policy »Have one »Both construction related and non-compliance LSC »When to implement EP 3: The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk.

33 EP 3 Policy Example # 1 SUBJECT:INTERIM LIFE SAFETY POLICY The XX Medical Center recognizes that construction and/or renovation activities have the potential to increase the risk of injury to staff, patients and/or visitors. Because of this potential, a program of risk evaluation and mitigation strategies has been developed to minimize these risks. The following procedures will be followed during all construction and/or renovation activities that have this potential. At the completion of the preliminary design phase and prior to beginning construction or renovation, an Interim Life Safety Measures, (ILSM), Review Checklist will be completed by the Construction Projects Manager or his designee. Identified Life Safety Deficiencies In addition to construction and renovation activities, interim life safety measures must be considered whenever there is an identified life safety deficiency. This could occur as a result of a periodic life safety assessment or as an item identified during a scheduled hazardous surveillance tour. Whenever a life safety code deficiency is identified a review will be conducted to determine the need for interim life safety measures. CRITIQUE: Covers the two major bases CONCERN: Boxed self in, all defs. Take OUT

34 Example # 2 Policy # 6602 Interim Life Safety Measures It is the policy of XX Memorial Medical Center to assess the need for Interim Life Safety Measures (ILSM) to ensure the safety of all building occupants during periods of construction or when significant deficiencies or impairments compromise the level of life safety protection provided by building Life Safety Features. ILSM apply to all personnel, (including construction workers) working in Health Care, Ambulatory Care Buildings, and any other occupancy classifications deemed appropriate by the Life Safety Officer or designee. ILSM must be assessed whenever a significant deficiency is identified or prior to the start of any construction project where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA). ILSM shall not be warranted for incidental short-term deficiencies. CRITIQUE: Covers the two major bases; does avoid the all deficiencies Concern: Who decides: significant and what is short-term. Add IN

35 Example # 2 addendum Policy # 6602 Interim Life Safety Measures (Same policy as Example # 2 with definitions) II. Definitions: Incidental short-term deficiencies: Minor transient deficiencies that only effect local areas, do not pose any systemic risks and will be corrected by the Maintenance department. Examples include the failure of one corridor smoke sensor which is flanked by other working sensors, dirty sprinkler heads and other deficiencies of similar magnitude. Significant Deficiencies: Life Safety Code deficiencies that pose systemic risks. Examples include blocking of egress corridors due to construction, impairments to smoke and/or fire barriers and impairments to suppression and detection systems greater than 4 hours. GOOD

36 Example # 3 Policy # 6602 Interim Life Safety Measures with definitions It is the policy of XX Memorial Medical Center to assess the need for Interim Life Safety Measures (ILSM) to ensure the safety of all building occupants during periods of construction or when significant deficiencies or impairments compromise the level of life safety protection provided by building Life Safety Features. ILSM apply to all personnel, (including construction workers) working in Health Care, Ambulatory Care Buildings, and any other occupancy classifications deemed appropriate by the Life Safety Officer or designee. ILSM must be assessed whenever a significant deficiency is identified or prior to the start of any construction project where ILSM are required as part of the Pre-Construction Risk Assessment (PCRA). ILSM shall not be warranted for incidental short-term deficiencies. The surveyor/ evaluator identifying the deficiency determines whether or not it is a significant or incidental short-term deficiency. The Life Safety Officer should be consulted in questionable situations and can ultimately overrule. CRITIQUE: Covers the two major bases; does avoid the all deficiencies aspect Concern: None Add IN

37 EP 3 – The ILSM Policy » »Have one » »Both construction related and non- compliance LSC » »When to implement

38 EP 3 – The ILSM Policy »What to do to protect occupants –EP 4 – 14 Policy example # 1 EP 3: The organization has a written interim life safety measure (ILSM) policy that covers situations when LSC deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the organization follows special measures to compensate for increased life safety risk. Prior to the start of the project, the project details and the ISLM Review Checklist will be reviewed with the Safety Officer, an Engineering Services Representative, the XX Construction Representative and the Contractor representative. Any additions or revisions to the checklist will be noted and will be added to the project procedures.

39 Two matrix checklists Two matrix checklists

40 ILSM EP # 8 On Matrix decided to increase hazard self inspections – crawl space for combustibles On Matrix decided to increase hazard self inspections – crawl space for combustibles Keep the documentation of those inspections for 3 years. Keep the documentation of those inspections for 3 years. –If not available – Indirect finding

41 Conclusion Covered ILSM background Covered ILSM background Real world major life safety factors Real world major life safety factors The important vulnerabilities of the ILSM policy The important vulnerabilities of the ILSM policy And some INs and OUTs for a good policy And some INs and OUTs for a good policy This presentation will be on the NEHES Webb site This presentation will be on the NEHES Webb site

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