In a recent Q&A on the FacilityCare website, consultant Brad Keyes answered a question about ILSM implementation.
Q: During our last survey the life safety code specialist discovered that two of our stairwells were deficient as far as the fire rating. The contractor did a lousy job as far as the two-hour rating in 1985 and I guess no one caught it since then. So 30 years later, thanks to the sharp eyes of our surveyor, we will fix it and it’s not going to be a walk in the park. My question is: Do we need to do a fire watch or would additional Interim Life Safety Measures (ILSM) fire drills be sufficient?
A: You have an apparent Life Safety Code (LSC) deficiency. You must assess that deficiency for alternative life safety measures in accordance with your ILSM policy. This is a must, regardless of who your accreditation organization is. This assessment must be made on the day that you discover the LSC deficiency.
Your ILSM policy must dictate what measures you will implement, if any, for this particular LSC deficiency.
Sustainability as a Baseline in Healthcare Facilities
Penobscot Valley Hospital Reports Data Security Incident
Ballad Health Acquires Land for Future Unicoi County Hospital
Why Healthcare Facilities Management Is Critical to Patient Safety 
Brookdale Senior Living Announces Acquisition of the Brookdale Galleria Community