Does TJC require documented ILSM assessments for all life safety code deficiencies, or is documenting ILSM assessments only required for the more significant life safety code deficiencies (>45 day items) ok?
Whenever a Life Safety Code deficiency is identified the organization should consider if an ILSM assessment is needed, regardless if it can be resolved in the 45 day corrective maintenance approach or PFI. What if the deficiency was significant and managed under the corrective maintenance approach, but took 40 days to complete? ILSM implementation is determined by the impact the deficiency may have on the occupants. Why not implement an ILSM to protect the occupants during this period?
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