Attachment J Interim Life Safety Measures Evaluation.pdf

INTERIM LIFE SAFETY MEASURES EVALUATION

West Palm Beach V.A Medical Center

When a Life Safety Code deficiency cannot be immediately corrected (within 24 hrs.) or during periods of construction please use this form for evaluation. (Please Circle Yes or No. If yes is circled please provide detail of action on the next page.) Evaluation referencing July 2019 TJC

Hospital Standards LS.01.02.01.

Reviewed By:_____________________________________________________

Signature:_______________________________________________________ Date:____________ 6/19 updated form

Hazard/Condition/Project:_______________________________________________________________________________________________________

Location:______________________________________________________________________________________________________________________________

YES OR NO 1. Does the hospital need to evacuate the building or notify the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 8 out of 24 hours (based on agreement letter between VHA and TJC effective September 4th, 2017) or a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building? Are Notification and fire watch times are documented? (If yes provide a copy of the fire watch log sheet.)

YES OR NO 2. Is there a need to post signage identifying the location of alternative exits to everyone affected? (If yes, provide a summary of what was added.)

YES OR NO 3. Do exits in affected areas need to be inspected daily? (If yes, provide what exits are monitored and create a monitoring document as proof of daily inspections)

YES OR NO 4. Is a temporary but equivalent fire alarm and detection systems needed for use when a fire system is impaired? (If yes, provide details as to what was added.)

YES OR NO 5. Does additional firefighting equipment need to be added? (If yes, provide a summary as to what equipment was added.)

YES OR NO 6. Is the use of temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire be required? (If yes, provide the type of barrier being used.)

YES OR NO 7. Will increased surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices be needed? (If yes, provide details as to what is being monitored.)

YES OR NO 8. Will storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level be needed? (If yes document what was removed from the affected area.)

YES OR NO 9. Will additional training to those who work in the hospital on the use of firefighting equipment. (If yes provide date(s) of training and a copy of the sign in sheet with summary as to what were staff trained on).

YES OR NO 10. Will one additional fire drill per shift or specialized training per quarter be needed? (if yes, provide training summary.)

YES OR NO 11. Do temporary systems need to be tested and inspected monthly? (If yes, the completion date of the tests shall be documented.)

YES OR NO 12. Does The hospital need to conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety? (If yes, provide a summary of the education provided.)

YES OR NO 13. Does the hospital train those who work in the hospital to compensate for impaired structural or compartmental fire safety features? (If yes, provide date(s) of training and a copy of the sign in sheet with summary as to what were staff trained on.)

YES OR NO 14. Other. Not addressed in above: The “other” ILSMs used are documented by selecting “other” and annotating the associated textbox in the hospital's Survey-Related Plan for Improvement (SPFI) within the Statement of Conditions™ (SOC).

INTERIM LIFE SAFETY MEASURES EVALUATION

West Palm Beach V.A Medical Center

When a Life Safety Code deficiency cannot be immediately corrected (within 24 hrs.) or during periods of construction please use this form for evaluation. (Please Circle Yes or No. If yes is circled please provide detail of action on the next page.) Evaluation referencing July 2019 TJC

Hospital Standards LS.01.02.01.

Reviewed By:_____________________________________________________

Signature:_______________________________________________________ Date:____________ 6/19 updated form

I.L.S.M Actions - Provide details including dates below.

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

6.____________________________________________________________________________