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HEALTHCARETJC / CMSRISK MANAGEMENT

LSRA & ILSM
Life Safety Risk Assessment & Interim Life Safety Measures

Maintaining compliance during healthcare construction

By Stanislav Samek, Samektra · 9 min read · Last updated April 18, 2026

What Is an LSRA?

A Life Safety Risk Assessment (LSRA) is a formal, documented evaluation of how a construction, renovation, or maintenance project will impact the life safety features of a healthcare facility. It is required by The Joint Commission (TJC) under standard PE.02.06.05 and by CMS through the Conditions of Participation whenever deficiencies in life safety code compliance exist or when construction activities compromise existing fire safety features TJC PE.02.06.05.

The LSRA process evaluates what fire protection and life safety systems will be affected — sprinklers impaired, fire walls breached, exit access blocked, fire alarm zones disabled — and determines what Interim Life Safety Measures (ILSM) must be implemented to maintain an equivalent level of safety.

When Is an LSRA Required?

•Any construction or renovation project in an occupied healthcare facility
•When sprinkler systems, fire alarms, or smoke detection must be taken out of service
•When fire-rated barriers (walls, doors, penetrations) are breached
•When means of egress (exit corridors, stairwells) are obstructed or rerouted
•When existing Life Safety Code deficiencies exist (Equivalency or waiver situations)
•During demolition activities that create dust, debris, or compromised compartments

The 11 Interim Life Safety Measures (ILSM)

When the LSRA identifies compromised life safety features, the facility must implement appropriate ILSMs from the following list. These are defined by NFPA 101, §4.6.10 and reinforced by TJC PE.02.06.05, EP 10 NFPA 101, §4.6.10.

1

Ensure exits are free and unobstructed

Post signage, maintain illuminated exit paths, provide temporary exits if needed.

2

Free and unobstructed access to fire alarm pull stations and extinguishers

Relocate if necessary and post directional signage.

3

Temporary fire alarm notification

Provide alternative means of notification when the fire alarm system is impaired — portable horns, PA system, phone trees.

4

Temporary smoke detection and compartmentation

Install temporary smoke detectors and fire barriers in affected areas.

5

Additional firefighting equipment

Place additional fire extinguishers in the construction area and adjacent spaces.

6

Fire watch

Assign trained fire watch personnel when sprinkler or alarm systems are impaired. Continuous during impairment.

7

Train staff in fire safety procedures

Brief all staff in the affected area on modified fire response, temporary exits, and code procedures.

8

Increase awareness among staff, patients, and visitors

Post signage, conduct briefings, include in shift handoff communications.

9

Enforce construction site storage, housekeeping, and hazard controls

No smoking in construction areas, proper storage of flammables, daily housekeeping.

10

Conduct additional fire drills

Conduct fire drills in the affected area at least quarterly — more frequently if warranted.

11

Inspect exits and construction areas daily

Safety officer or designee walks the affected area daily to verify ILSMs are in place and effective.

ASHE Resources

The American Society for Health Care Engineering (ASHE) provides excellent templates and guidance documents for conducting LSRAs and implementing ILSMs. These are considered industry best practices and are frequently referenced during TJC surveys.

LSRA Risk Assessment Matrix

Use this interactive matrix to assess life safety deficiencies and determine if Interim Life Safety Measures (ILSM) are required. Select the impact and severity of the deficiency to calculate the risk level.

▶ Watch on YouTube

See ILSM implementation in action on What The Fire Code — including life safety inspections in hospitals and construction compliance.

Watch on YouTube →

Frequently Asked Questions

What is the difference between LSRA and ILSM?
LSRA (Life Safety Risk Assessment) is the ASSESSMENT TOOL — a formal, documented evaluation that identifies how a construction project, renovation, or existing deficiency will impact life safety features. ILSM (Interim Life Safety Measures) is the resulting ACTION PLAN — the specific compensatory measures (fire watch, extra drills, temporary exits, staff education) implemented to maintain an equivalent level of safety while the deficiency exists. Never conflate the two: the LSRA identifies the risk, the ILSM compensates for it.
When is an LSRA required?
An LSRA is required under TJC PE.02.06.05 and CMS 42 CFR §482.41 any time life safety features are impaired. Common triggers: sprinkler impairment, fire alarm impairment, fire barrier breach, blocked or rerouted egress, existing Life Safety Code deficiencies under equivalency or waiver, and any construction or renovation in an occupied healthcare facility. The assessment must be dated, signed by a qualified assessor, and kept on file for the duration of the impairment plus a required retention period.
How many Interim Life Safety Measures are there?
NFPA 101 §4.6.10 defines 11 standard ILSMs: (1) ensure exits are free and unobstructed; (2) free access to pull stations and extinguishers; (3) temporary equivalent fire alarm and detection systems when originals are impaired; (4) temporary measures when sprinklers are impaired; (5) increased surveillance including fire watch; (6) temporary construction partitions; (7) increased hazardous-area monitoring; (8) conduct at least two fire drills per shift per quarter; (9) increased staff education on fire safety; (10) increased hot-work controls; and (11) increased combustible and flammable storage controls. Pick the ones that match the specific deficiency identified in the LSRA.
Who performs the LSRA?
A qualified assessor — typically the facility safety officer, a life safety consultant, or a fire protection engineer — performs the LSRA in collaboration with clinical leadership, facilities management, infection control (for ICRA integration), and the contractor. The assessment must be multidisciplinary because a construction activity that passes fire safety review may still fail infection control review, and vice versa. TJC expects sign-off from each discipline before construction starts.
How long does an ILSM remain active?
For the duration of the life safety impairment — not longer, not shorter. Once the underlying deficiency is corrected (sprinkler system restored, fire barrier rebuilt, construction complete), the ILSM is deactivated and documented. LSRA reassessment is required whenever the scope of the impairment changes — new construction phase, unexpected deficiency discovered, deadline extended. Treating the LSRA as a one-time document instead of a living assessment is the most common TJC citation in this area.
What is a fire watch and when is it required?
A fire watch is a dedicated person continuously patrolling an area with impaired fire detection or suppression, whose sole responsibility is to detect fire and activate the alarm. NFPA 101 and most jurisdictions require fire watch when sprinkler impairment exceeds 10 hours in a 24-hour period or when fire alarm impairment exceeds 4 hours. The fire watch must be trained, have a reliable means to notify emergency services, and maintain a written log of each patrol round. Fire watch is ILSM #5 and is the most common compensatory measure triggered by the LSRA.
Do TJC and CMS enforce the same ILSM requirements?
They reference the same NFPA 101 §4.6.10 framework, but CMS enforcement is through K-tag K-0920 (Interim Life Safety Measures) while TJC enforcement is through PE.02.06.05 EP 10. Both require the same 11 measures and the same LSRA-based implementation. Facilities accredited by TJC with deemed status for CMS must satisfy both surveys, so the practical requirement is identical: a documented LSRA and an active, executed ILSM program for every known impairment.

References

1. NFPA 101: Life Safety Code, §4.6.10 — Interim Life Safety Measures.

2. The Joint Commission: PE.02.06.05 — Building and Fire Protection Features.

3. CMS Conditions of Participation: 42 CFR §482.41 — Physical Environment.

4. ASHE: American Society for Health Care Engineering Resources.

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