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HEALTHCARETJC / CMSRISK MANAGEMENT

LSRA & ILSM
Life Safety Risk Assessment & Interim Life Safety Measures

Maintaining compliance during healthcare construction

By Samektra · April 2026 · 9 min read

What Is an LSRA?

A Life Safety Risk Assessment (LSRA) is a formal, documented evaluation of how a construction, renovation, or maintenance project will impact the life safety features of a healthcare facility. It is required by The Joint Commission (TJC) under standard PE.02.06.05 and by CMS through the Conditions of Participation whenever deficiencies in life safety code compliance exist or when construction activities compromise existing fire safety features TJC PE.02.06.05.

The LSRA process evaluates what fire protection and life safety systems will be affected — sprinklers impaired, fire walls breached, exit access blocked, fire alarm zones disabled — and determines what Interim Life Safety Measures (ILSM) must be implemented to maintain an equivalent level of safety.

When Is an LSRA Required?

•Any construction or renovation project in an occupied healthcare facility
•When sprinkler systems, fire alarms, or smoke detection must be taken out of service
•When fire-rated barriers (walls, doors, penetrations) are breached
•When means of egress (exit corridors, stairwells) are obstructed or rerouted
•When existing Life Safety Code deficiencies exist (Equivalency or waiver situations)
•During demolition activities that create dust, debris, or compromised compartments

The 11 Interim Life Safety Measures (ILSM)

When the LSRA identifies compromised life safety features, the facility must implement appropriate ILSMs from the following list. These are defined by NFPA 101, §4.6.10 and reinforced by TJC PE.02.06.05, EP 10 NFPA 101, §4.6.10.

1

Ensure exits are free and unobstructed

Post signage, maintain illuminated exit paths, provide temporary exits if needed.

2

Free and unobstructed access to fire alarm pull stations and extinguishers

Relocate if necessary and post directional signage.

3

Temporary fire alarm notification

Provide alternative means of notification when the fire alarm system is impaired — portable horns, PA system, phone trees.

4

Temporary smoke detection and compartmentation

Install temporary smoke detectors and fire barriers in affected areas.

5

Additional firefighting equipment

Place additional fire extinguishers in the construction area and adjacent spaces.

6

Fire watch

Assign trained fire watch personnel when sprinkler or alarm systems are impaired. Continuous during impairment.

7

Train staff in fire safety procedures

Brief all staff in the affected area on modified fire response, temporary exits, and code procedures.

8

Increase awareness among staff, patients, and visitors

Post signage, conduct briefings, include in shift handoff communications.

9

Enforce construction site storage, housekeeping, and hazard controls

No smoking in construction areas, proper storage of flammables, daily housekeeping.

10

Conduct additional fire drills

Conduct fire drills in the affected area at least quarterly — more frequently if warranted.

11

Inspect exits and construction areas daily

Safety officer or designee walks the affected area daily to verify ILSMs are in place and effective.

ASHE Resources

The American Society for Health Care Engineering (ASHE) provides excellent templates and guidance documents for conducting LSRAs and implementing ILSMs. These are considered industry best practices and are frequently referenced during TJC surveys.

▶ Watch on YouTube

See ILSM implementation in action on What The Fire Code — including life safety inspections in hospitals and construction compliance.

Watch on YouTube →

References

1. NFPA 101: Life Safety Code, §4.6.10 — Interim Life Safety Measures.

2. The Joint Commission: PE.02.06.05 — Building and Fire Protection Features.

3. CMS Conditions of Participation: 42 CFR §482.41 — Physical Environment.

4. ASHE: American Society for Health Care Engineering Resources.

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Discussion (2)

You
MR
Mike R.Fire Inspector· 3 days ago

Great breakdown of the technical details. The NFPA 25 maintenance table is exactly what I needed for my ITM schedule.

▲ 8Reply
SL
Sarah L.Safety Officer· 1 week ago

Really clear explanation. Would love to see a companion video walkthrough of the inspection process.

▲ 5Reply