Interim Life Safety Measures.pdf
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This is a Medical Center Policy (MCP 001S.26) from the Durham VA Healthcare System establishing procedures for evaluating and implementing Interim Life Safety Measures (ILSM) during construction projects and when significant Life Safety Code (LSC) deficiencies are identified.
The policy applies to all construction workers and medical center personnel within construction areas or adjacent areas affected by construction activities. ILSM are compensating measures implemented when LSC requirements cannot be met. The policy establishes that the Contracting Officer's Representative (COR) or Construction Lead Person (CLP) must complete an ILSM evaluation and submit it to the Chief of Engineer and Safety Manager for approval within 14 days of project initiation. The Chief, Engineering Service is responsible for reviewing evaluations and ensuring implementation, enforcement, and documentation of necessary measures. The Chief, Safety Service (Safety Manager) must review ILSM evaluations for regulatory compliance and develop implementation procedures immediately upon discovery of LSC deficiencies. The VA Medical Facility Director is responsible for overall facility compliance and appropriate corrective action. Deficiencies scored as "4" (indirect impact) by The Joint Commission are not considered significant and may be evaluated as a group and summarized in Environment of Care Committee minutes. This policy is effective November 30, 2024, with recertification scheduled for December 1, 2029, and supersedes previous MCP 138.27 from September 2020.
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November 2024 MCP 001S.26
INTERIM LIFE SAFETY MEASURES (ILSM)
MCP 001S.26
Durham VA Healthcare System Durham, North Carolina 27705
Signatory Authority:
Medical Director, Durham VA Healthcare System
Responsible Owner:
Safety Service, Chief
Rescinded Document:
See Paragraph 8
Effective Date:
November 30, 2024
Recertification Date:
December 1, 2029
1. SUMMARY OF CONTENT
The need for Interim Life Safety Measures (ILSM) will be addressed during project development and evaluated throughout the construction process. ILSM will apply to all construction workers as well as any medical center personnel within the construction areas or in any adjacent areas affected by the construction. ILSM will also be addressed when significant existing Life Safety Code (LSC) deficiencies are identified. LSC deficiencies that would be scored as a "4" (indirect impact) by The Joint Commission under the Life Safety Standards would not be considered significant. ILSM are intended to provide compensating measures when the requirements of the LSC cannot be met. All lLSM actions will be documented.
Deficiencies that are not significant may be evaluated as a group and summarized in the Environment of Care Committee (EOCC) minutes.
2. POLICY
This medical center policy (MCP 558-22-001S.26) establishes the evaluation for a need of an ILSM prior to the start of any construction project, and continually through the duration of the project. The COR or CLP will complete an ILSM evaluation and submit it to the Chief of Engineer and the Safety Manager for approval.
3. JUSTIFICATION
To establish criteria for evaluating and determining when, and to what extent, Interim Life Safety Measures (ILSM) are necessary for the following conditions:
Significant existing/discovered Life Safety Code (LSC) deficiencies, and deficiencies or conditions because of construction.
4. RESPONSIBILITIES
a. VA Medical Facility Director. The VA medical facility Director is responsible for ensuring overall VA medical facility compliance with this policy, and appropriate corrective action is taken if non-compliance is identified.
b. The Contracting Officer's Representative (COR) and Construction Lead Person (CLP). The Contracting Officer's Representative (COR) and Construction Lead Person (CLP) is responsible for evaluating the project concerning ILSM. If ILSM are found to be necessary to the project, the COR will develop procedures for the implementation, enforcement, and documentation of the ILSM within 14 days of the project.
c. The Chief, Engineering Service (Chief Engineer) or designee. The Chief, Engineering Service (Chief Engineer) or designee is responsible for reviewing the ILSM evaluations submitted from the COR or CLP and ensuring the implementation, enforcement, and documentation of any necessary ILSM.
d. The Chief, Safety Service, (Safety Manager) or designee. The Chief, Safety
Service, (Safety Manager) or designee is responsible for:
(1) Reviewing the ILSM evaluations to ensure compliance with applicable regulations.
(2) Evaluating the existing LSC deficiencies. If ILSM are found to be necessary, the Safety Manager or designee will develop procedures for the implementation, enforcement, and documentation of the ILSM immediately upon discovery of the LSC deficiency.
5. OTHER PARAGRAPHS
“None.”
6. DEFINITIONS
“None.”
7. REFERENCES
a. Joint Commission Comprehensive Accreditation Manual for Hospitals, Long Term Care, Home Care, and Laboratory and Point-of-Care Testing, (current editions).
b. NFPA® 101, Life Safety Code, (current edition).
https://edition.jcrinc.com/
8. RESCISSION
MCP 138.27, Interim Life Safety Measures, September 2020
9. REVIEW
This MCP will be reviewed, at minimum, at recertification and including when there are change to the governing document.
10. RECERTIFICATION
This MCP is scheduled for recertification on or before the last working day of November 2029 – 5 years from effective date. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.
11. SIGNATORY AUTHORITY
Peter Tillman, MPA, FACHE Associate Director, Durham VA Health Care System
Alyshia Smith, DNP Executive Director, Durham VA Healthcare System
Date Approved:
NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: MCPs are available on the Durham VAHCS SharePoint: Durham VAHCS Medical Center Policies https://dvagov.sharepoint.com/sites/durham/QSVService/DVAHCS%20Medical%20Center%20Policies/Forms/AllItems.aspx https://dvagov.sharepoint.com/sites/durham/QSVService/DVAHCS%20Medical%20Center%20Policies/Forms/AllItems.aspx
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