ILSM INITIAL ASSESSMENT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Project name and location

• Project start date

  Date

Potential or existing Code Deficiencies

• Is there a problem with patient room door latching?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select PM inspects required exits daily to assure unobstructed egress free and unobstructed access to emergency services Temp construction partitions are smoke tight and rated Provide staff additional training increase hazard surveillance rounds

  • PM inspects required exits daily to assure unobstructed egress
  • free and unobstructed access to emergency services
  • Temp construction partitions are smoke tight and rated
  • Provide staff additional training
  • increase hazard surveillance rounds

• Is a code complying barrier lacking?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select Additional fire fighting equipment is available smoking is prohibited control combustibles increase hazard surveillance

  • Additional fire fighting equipment is available
  • smoking is prohibited
  • control combustibles
  • increase hazard surveillance

• Do fire exit doors discharge improperly?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select PM inspects required exits daily to assure unobstructed egress free and unobstructed access to emergency services Temp construction partitions are smoke tight and rated Provide staff additional training increase hazard surveillance rounds

  • PM inspects required exits daily to assure unobstructed egress
  • free and unobstructed access to emergency services
  • Temp construction partitions are smoke tight and rated
  • Provide staff additional training
  • increase hazard surveillance rounds

• Will any approved exit be blocked or obstructed with a barrier which is not continuously supervised AND cannot be immediately removed in the case of a fire alarm or emergency egress is required?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select PM daily inspects required egress to assure egress is unobstructed Ensure free and in obstructed access to emergency services Temporary construction partitions are smoke tight and rated appropriately Conduct additional training for fire response team Increase hazard surveillance rounds Notify emergency forces

  • PM daily inspects required egress to assure egress is unobstructed
  • Ensure free and in obstructed access to emergency services
  • Temporary construction partitions are smoke tight and rated appropriately
  • Conduct additional training for fire response team
  • Increase hazard surveillance rounds
  • Notify emergency forces

• Are any fire alarm systems including including initiating alarm systems out of service or not functioning properly?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select A temporary but equivalent systems hall be provided provide additional fire fighting equipment Conduct additional training of fire response team contact the fire department contact insurance carrier

  • A temporary but equivalent systems hall be provided
  • provide additional fire fighting equipment
  • Conduct additional training of fire response team
  • contact the fire department
  • contact insurance carrier

• Will the fire detection system be taken out of service for more than 4 hours in a 24 hour period?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select A temporary but equivalent systems hall be provided provide additional fire fighting equipment Conduct additional training of fire response team contact the fire department contact insurance carrier

  • A temporary but equivalent systems hall be provided
  • provide additional fire fighting equipment
  • Conduct additional training of fire response team
  • contact the fire department
  • contact insurance carrier

• Is there a significant lacking or breaching smoke or fire barrier including large penetrations?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select temp construction partitions are smoke tight and rated provide additional firefighting equipment and train personnel develop and enforce storage, housekeeping, and debris removal that reduce flammable and combustible materials conduct additional training increase hazard surveillance rounds

  • temp construction partitions are smoke tight and rated
  • provide additional firefighting equipment and train personnel
  • develop and enforce storage, housekeeping, and debris removal that reduce flammable and combustible materials
  • conduct additional training
  • increase hazard surveillance rounds

• Will there be major renovation of of an occupied floor with some demolition/alteration processes?

  Yes

  No

  N/A

• The following ILSM will beImplemented

  Select PM inspects egress and exits daily to ensure unobstructed egress Temp construction partitions are smoke tight and rated Develop and enforce storage, housekeeping, and debris removal to reduce flammable and combustible materials provide additional staff education increase hazard surveillance rounds

  • PM inspects egress and exits daily to ensure unobstructed egress
  • Temp construction partitions are smoke tight and rated
  • Develop and enforce storage, housekeeping, and debris removal to reduce flammable and combustible materials
  • provide additional staff education
  • increase hazard surveillance rounds

• Will there be any rerouting of traffic to the Emergency Department, normal access obstructed?

  Yes

  No

  N/A

• The following ILSM will be implemented

  Select Ensure free and obstructed access to emergency services a temporary but equivalent system is provided for fire alarms

  • Ensure free and obstructed access to emergency services
  • a temporary but equivalent system is provided for fire alarms

• Is a hazardous area not protected?

  Yes

  No

  N/A

• Select A temporary but equivalent fire alarm, detection and/or suppression system shall be provided Temporary construction barriers are smoke proof and rated provide additional fire fighting equipment Develop and enforce storage, housekeeping, and debris removal to reduce flammable and combustible materials provide extra staff training increase hazard surveillance rounds

  • A temporary but equivalent fire alarm, detection and/or suppression system shall be provided
  • Temporary construction barriers are smoke proof and rated
  • provide additional fire fighting equipment
  • Develop and enforce storage, housekeeping, and debris removal to reduce flammable and combustible materials
  • provide extra staff training
  • increase hazard surveillance rounds

Emergency contact numbers

• Protect managers name and contact information