ILSM - Grouping of Survey-related Plans for Improvement (SPFI) 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.
^The Survey Related PFI (SPFI) tab is located on the Statement of Conditions page accessed via the organization's secure extranet site.
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.
^The Survey Related PFI (SPFI) tab is located on the Statement of Conditions page accessed via the organization's secure extranet site.
Manual:
Behavioral Health
Chapter:
Life Safety LS
First published date: April 11, 2016
This Standards FAQ was first published on this date.
This page was last updated on March 22, 2022
with update notes of: Editorial changes only
Types of changes and an explanation of change type:
Editorial changes only: Format changes only. No changes to content. |
Review only, FAQ is current: Periodic review completed, no changes to content. |
Reflects new or updated requirements: Changes represent new or revised requirements.
Get Extra Help with Books and E-books
Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.
Stay Informed with Online Education
Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.
Reach Your Safety Goals with eProducts
Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.