Overview
Direct answer: Interim Life Safety Measures (ILSM) are temporary actions a healthcare facility uses to protect patients, staff, and visitors when Life Safety Code deficiencies cannot be corrected immediately or when construction creates added fire- or egress-related risk. A compliant ILSM process evaluates each condition, selects measures that match the risk, documents implementation, monitors the measures, and closes them only after the underlying condition is verified as corrected.
Last verified: August 10, 2026 | Applies to: Hospitals and critical access hospitals using Joint Commission accreditation, plus other healthcare facilities that use ILSM or equivalent risk-mitigation processes.
What are Interim Life Safety Measures?
ILSMs are compensating measures—not permanent repairs. They reduce exposure while a fire protection feature, rated assembly, means of egress component, or construction condition remains deficient. The facility’s policy should define when an evaluation is required, who completes it, how the level of risk is determined, which measures are available, and who has authority to discontinue them.
The Joint Commission’s hospital Life Safety and Environment of Care document list identifies an ILSM policy and evidence that required measures are implemented. CMS requires applicable providers to comply with the adopted Life Safety Code and Health Care Facilities Code. Facilities should therefore connect ILSM decisions to their broader fire-safety, construction, impairment, and corrective-action programs.
When should a healthcare facility perform an ILSM evaluation?
Perform and document an evaluation whenever a Life Safety Code deficiency cannot be corrected immediately and whenever construction, renovation, demolition, or temporary work could reduce existing protection. The evaluation should occur promptly after discovery and before planned work begins when the risk can be anticipated.
• A fire or smoke barrier is breached, incomplete, or temporarily opened.
• A fire door, smoke door, exit enclosure, or protected opening cannot perform as intended.
• An exit, corridor, stair, or access route is obstructed, narrowed, rerouted, or temporarily closed.
• A fire alarm, sprinkler, suppression, smoke-control, or detection component is impaired.
• Construction increases combustible loading, ignition sources, dust, debris, or unauthorized access.
• Temporary partitions, ceilings, utilities, or penetrations alter the facility’s approved life safety strategy.
• A deficiency identified during rounding, inspection, testing, construction, or survey will remain open beyond immediate correction.
How to complete an ILSM risk assessment
• Describe the condition. Record the exact location, affected system or feature, discovery date, responsible department, and supporting photographs or work-order references.
• Identify who and what is exposed. Consider patient acuity, defend-in-place needs, sleeping rooms, egress routes, adjacent smoke compartments, hazardous operations, and construction activity.
• Evaluate existing protection. Determine which alarms, sprinklers, barriers, staff response capabilities, and alternate routes remain available.
• Select proportionate measures. Apply the measures required by facility policy and add controls when the specific risk warrants them.
• Assign ownership and frequency. Name the person or department responsible for every measure and specify when it must occur.
• Monitor and escalate. Reassess when the scope, duration, occupancy, work phase, or risk changes.
• Verify closure. Inspect the completed repair, restore affected systems, close associated permits and work orders, and retain evidence that temporary measures ended appropriately.
Common ILSM measures in healthcare facilities
The correct combination depends on the facility’s policy and the specific condition. Common measures include maintaining unobstructed exits; increasing surveillance of buildings, grounds, or construction areas; enforcing storage and housekeeping controls; providing temporary fire protection; posting signage and alternate routes; increasing staff education; conducting additional fire drills; inspecting temporary systems; coordinating fire watch or evacuation procedures for qualifying impairments; and communicating hazards to affected departments.
Do not treat a generic checklist as the risk assessment. Selecting every box without explaining the hazard can be as weak as selecting none. The record should show why each measure was or was not needed and how the chosen controls address the actual exposure.
ILSM during healthcare construction
Construction conditions change quickly. A project that was adequately controlled yesterday may introduce new penetrations, blocked corridors, hot work, disabled devices, combustible loading, or temporary partitions today. Coordinate the ILSM process with preconstruction risk assessment, infection-control risk assessment, hot-work permits, utility shutdowns, above-ceiling permits, contractor orientation, daily project inspections, and facility emergency procedures.
ILSM documentation checklist
• Unique record or work-order number and exact location
• Description of the deficiency or construction hazard
• Date and time discovered or planned start date
• Risk evaluation and rationale
• Selected measures, owners, frequencies, and start dates
• Notifications to affected leaders, staff, contractors, and safety personnel
• Fire-watch, drill, inspection, education, and temporary-system records when applicable
• Target correction date and escalation history
• Repair verification, system restoration, and closure approval
• Links to drawings, permits, photographs, findings, and corrective-action records
Common ILSM program failures
Survey vulnerability often comes from process gaps rather than the absence of a policy. Examples include evaluations completed days after discovery, measures copied from unrelated projects, missing evidence that rounds or drills occurred, expired target dates, construction changes that never triggered reassessment, and records closed before field verification. Another warning sign is a long list of open deficiencies with no clear distinction between routine work orders and conditions requiring interim protection.
Does every life safety deficiency require every ILSM?
No. The facility should evaluate the condition under its policy and apply measures that match the risk. However, required impairment procedures and mandatory policy triggers still apply.
Can a work order replace the ILSM record?
A work order can support the record, but it rarely documents the full risk decision, temporary controls, monitoring evidence, and closure verification by itself.
When can ILSM be discontinued?
Discontinue measures only after the underlying condition is corrected, affected protection is restored, and an authorized person verifies closure. If the scope or risk merely changes, reassess rather than automatically closing the record.
How Life Safety Express can help
Life Safety Express helps healthcare organizations evaluate life safety deficiencies, strengthen ILSM policies and forms, inspect construction and above-ceiling conditions, verify corrective work, and organize survey-ready evidence. Explore our healthcare life safety services or contact Life Safety Express for facility-specific support.
Official sources
• CMS Life Safety Code and Health Care Facilities Code requirements
• Joint Commission Hospital Life Safety and Environment of Care Document List
• Joint Commission Life Safety Code Resources
This article provides general compliance information and is not a substitute for a facility-specific code analysis, accreditation interpretation, or authority-having-jurisdiction determination.