ILSM Activation Checklist

Interim Life Safety Measures activation checklist for healthcare and institutional occupancies. Covers all 11 ILSMs required when life safety deficiencies exist.

NFPA 101 §4.6.10

INSPECTOR

LOCATION / FACILITY

DATE

Progress: 0 / 14 items0%

Assessment

Identify the life safety deficiency triggering ILSM activation (construction, system impairment, or survey finding)§4.6.10.1

Document the specific code section(s) affected and the scope of the deficiency

Determine the areas and occupants affected by the deficiency

Include floor, wing, department, and approximate occupant count

Assess whether the building can continue to be safely occupied with ILSMs in place§4.6.10.2

If risk is too high, consider partial or full evacuation

Notification

Notify administration and the safety officer of the deficiency and ILSM activation

Include scope, expected duration, and responsible parties

Notify the local fire department and AHJ

Required when fire protection systems are impaired

Brief all affected staff on ILSM procedures and their roles§4.6.10.3(3)

Include temporary evacuation procedures and fire response

Protective Measures

Post fire watch in affected areas — patrol at least every 30 minutes§4.6.10.3(1)

Fire watch must have communication device and know how to activate the alarm

Increase surveillance of construction areas and impaired zones§4.6.10.3(2)

Enforce smoking restrictions in and near affected areas§4.6.10.3(4)

Provide additional firefighting equipment (extinguishers) in affected areas§4.6.10.3(5)

Place temporary extinguishers near construction and impaired areas

Ensure temporary but equivalent fire alarm detection and notification in affected areas§4.6.10.3(6)

Portable smoke detectors, air horns, or manual notification devices

Conduct additional fire drills in affected areas (minimum 1 per shift per quarter during ILSM period)§4.6.10.3(7)

Drills must address the specific ILSM scenario and temporary evacuation routes

Documentation

Complete ILSM assessment form with deficiency description, start date, affected areas, and measures implemented§4.6.10.4

Retain documentation for review by CMS, TJC, or state surveyors

Document daily ILSM rounds and fire watch logs — retain until deficiency is resolved and ILSMs are deactivated

Include date, time, inspector name, and observations for each round

Notes & Deficiencies

IMPORTANT

ILSMs must remain in effect until the life safety deficiency is fully corrected. In healthcare occupancies accredited by The Joint Commission (TJC), ILSM compliance is a key survey focus under EC.02.06.05. CMS surveyors will review ILSM documentation during Life Safety Code surveys. Failure to implement ILSMs can result in Immediate Jeopardy findings.