The hospital protects occupants during periods when the Life Safety Code is not met or during...

(1)

The hospital has a written interim life safety measures (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital implements PE.03.02.01, EPs 2–15, to compensate for increased life safety risk. The criteria include the assessment process to determine when ILSM are implemented. Note: For any Life Safety Code deficiency that cannot be immediately corrected during survey, the hospital identifies which ILSM in its policy will be implemented until the issue is corrected.

(2)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours in an occupied building. Notification and fire watch times are documented. (For full text, refer to NFPA 101-2012: 9.6.1.6; 9.7.6; NFPA 25-2011: 15.5.2)

(3)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital posts signage identifying the location of alternative exits to everyone affected.

(4)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital inspects exits in affected areas on a daily basis. The need for these inspections is based on criteria in the hospital's interim life safety measures policy.

(5)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired. The need for equivalent systems is based on criteria in the hospital's interim life safety measures policy.

(6)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital's interim life safety measures policy.

(7)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital uses temporary construction partitions that are smoke-tight or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire. The need for these partitions is based on criteria in the hospital's interim life safety measures policy.

(8)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. The need for increased surveillance is based on criteria in the hospital's interim life safety measures policy.

(9)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level. The need for these practices is based on criteria in the hospital's interim life safety measures policy.

(10)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital provides additional training to those who work in the hospital on the use of firefighting equipment. The need for additional training is based on criteria in the hospital's interim life safety measures policy.

(11)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital conducts one additional fire drill per shift per quarter. The need for additional drills is based on criteria in the hospital's interim life safety measures policy.

(12)

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital inspects and tests temporary systems monthly. The completion date of the tests is documented. The need for these inspections and tests is based on criteria in the hospital's interim life safety measures policy.

(13)

The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. The need for education is based on criteria in the hospital's interim life safety measures policy.

(14)

The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features. The need for training is based on criteria in the hospital's interim life safety measures policy. Note: Compartmentalization is the concept of using various building components (for example, fire-rated walls and doors, smoke barriers, fire-rated floor slabs) to prevent the spread of fire and the products of combustion so as to provide a safe means of egress to an approved exit. The presence of these features varies, depending on the building occupancy classification.

(15)

The hospital's policy allows the use of other interim life safety measures (ILSM) not addressed in EPs 3–14. Note: The other ILSM used are documented by selecting “other” and annotating the associated text box in the hospital's Survey-Related Plan for Improvement within the Statement of Conditions™.