Immediate Threat to Health or Safety

What triggers an “Immediate Threat to Health or Safety” condition in the environment of care?

Failure to maintain the following four critical facilities systems may trigger an Immediate Threat to Health or Safety condition:

1. An unaddressed issue with the fire alarm system

2. An unaddressed issue with the sprinkler system

3. An unaddressed issue with the emergency power supply system

4. An unaddressed issue with the medical gas master panel

Compromised exits can also lead to a possible Immediate Threat to Health or Safety condition. Organizations should regularly check these systems to ensure that any issues are being addressed effectively, including whether the appropriate interim life safety measures (ILSM) are in place.

Maintaining the “integrity of the means of egress” was the second most cited (50%) problem area for hospitals in 2010. I’m assuming that if TJC surveyors find inappropriately locked doors, blocked exits or too much corridor clutter along the path of egress, they may cite the hospital for an immediate threat to health or safety (ITHS).