Our consulting teams are observing instances in which, during facility documentation reviews, inspections of fire and smoke dampers revealed that some failed the initial inspection. Repairs were performed on the affected devices, which passed re-inspection. However, in some instances, the time between the initial inspection that identified failures and the completion of repairs with re-inspection was sometimes months apart, with no documented evidence of an Interim Life Safety Measure(ILSM) review/implementation for the lag time. It is imperative that repairs to the dampers be expedited to reduce the risk to the facility in the event of a fire. If any of these dampers are impaired in their ability to function properly, the organization must implement appropriate ILSM measures to mitigate the risk. This may include notification of local fire departments, increased monitoring, temporary smoke/fire barricades, staff education/notification, and drills. Organizations should ensure they have policies/plans that address the implementation of ILSM during the “downtime” of fire suppression systems and equipment and implement them accordingly. It’s imperative to document the implementation of ILSM to provide the surveyor with the evidence that these safety measures were in place during repairs. Refer to Federal, state, and local codes, including NFPA 101-2012, for more information.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
