to main content ILSM - Policy Scope | Nursing Care Center | Life Safety LS | The Joint Commission
ILSM - Policy Scope

What must an Interim Life Safety Measure policy contain?

Any examples are for illustrative purposes only. 

In order to evaluate and implement an effective plan for Life Safety code deficiency mitigation, an Interim Life Safety Measure
(ILSM) policy must consist of the following:  
  • State that the process is applicable to 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 (PFIs) 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.
  • 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.  
Reference LS.01.02.01
Manual: Nursing Care Center
Chapter: Life Safety LS
New or updated requirements last added: November 13, 2023. New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: November 13, 2023 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 11, 2016 This Standards FAQ was first published on this date.
This page was last updated on November 13, 2023 with update notes of: Reflects new or updated requirements 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.
Was this response helpful?

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form

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.

Can't Find What You're Looking For?

If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG).

Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. The Joint Commission no longer answers questions submitted by students or vendors. Thank you for your understanding.