The Life Safety Code provides the minimum design requirements for which a building is to be constructed and considered safe for occupant use. The Joint Commission, Centers for Medicare & Medicaid Services and other authorities having jurisdiction (AHJs) that utilize the National Fire Protection Association’s NFPA 101®, Life Safety Code®, require compliance for all new and existing occupancies. 

The Life Safety Code not only provides information on design, but acknowledges that there will be times when a building may not be in total compliance, as follows:

  • Section Conditions for occupancy. No new construction or existing building shall be occupied in whole or part in violation of the provisions of this code unless the following conditions exist: 1) A plan of correction has been approved; 2) the occupancy classification remains the same; and 3) no serious life safety hazard exists as judged by the AHJ.
  • Section Occupied during construction. Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 
  • Section 4.6.6: Non-compliance. Limited but reasonable time, commensurate with the magnitude of expenditure, disruption of services and degree of hazard, shall be allowed for compliance with any part of this code for existing buildings.  

The purpose of Interim Life Safety Measures (ILSMs) is to mitigate risk by enacting measures to compensate for a decreased level of life safety when a facility is not in compliance with the Life Safety Code. It may be difficult to cover each situation, but the ILSM should provide a basis for how to determine what should be done when not in compliance. To help in determining when an ILSM is needed, the American Society for Health Care Engineering has developed a life safety risk assessment tool that members can access in the resource box. The tool allows for an organization to document the severity of occurrence and the impact of a deficiency.