Staff training for ILSMs must mirror the risks involved

When it comes to interim life safety measures (ILSM) under LS.01.02.01, poor staff education can result in some exposure during survey, minimally as a direct impact finding. Problems can also lead to conditional and preliminary denial of accreditation from The Joint Commission.

The means of providing ILSM education, while largely self-determined, need to legitimately reflect the risks that are present in the environment as the result of whatever work is being done. Smaller scope projects of fairly short duration will usually indicate an education plan of less complexity, while large-scale projects with longer timeframes will generally indicate something with a little more heft, if you will.

Looking specifically at LS.01.02.01, EPs 13 and 14, there are specific expectations of these processes:

• EP 13 notes “education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety”
• EP 14 mentions the “hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features”

Without a robust risk assessment process in place, you may be hard-pressed to convince a surveyor about the sufficiency of any ILSM choices you implement.