Life Safety Assessment™ (LSA)

Life Safety Assessment™ (LSA)

We provide you with an electronic LSA to help you quickly minimize costs of deficiencies.

To earn and maintain accreditation, a hospital must undergo an on-site survey by The Joint Commission survey team. The Joint Commission surveys are unannounced and occur 18 to 36 months after the previous unannounced survey. The survey team can include one or more health care professionals, including a physician, nurse, life safety code specialist, or hospital administrator who has senior management level experience.

The survey process evaluates actual care processes by tracing patients through the care, treatment and services they received. It also analyzes key operational systems that directly impact the quality and safety of patient care.

Life Safety Assessment ™ is a proactive document that helps an organization to do a critical self-assessment of its current level of compliance and describe how to resolve any Life Safety Code (LSC) deficiencies. The Life Safety Assesment was created to be a living, ongoing management tool that should be used in a management process that continually identifies, assesses, and resolves LSC deficiencies.

Accredited organizations can now complete part 2 (Basic Building Information) and part 4 (Plan for Improvement) of the Life Safety Assessment electronically from The Joint Commission Connect extranet website

This Life Safety Assessment (LSA) compliance document has been developed to help organizations maintain a fire safe environment and demonstrate compliance with the intent of standards that require newly constructed and existing environments of care be designed and maintained to comply with the Life Safety Code.

The LSA compliance document consists of the following four parts:

  • Part 1: Introduction & Instructions – contains general information and guidance to aid you in completing Parts 2 through 4.
  • Part 2: Basic Building Information (BBI) – collects general information about each building occupied by patients/residents/clients.
  • Part 3: Life Safety Assessment (LSA) – assesses your organization’s general compliance withthe requirements of NFPA 101® – 2000; Life Safety Code (LSC).
  • Part 4: Plan for Improvement (PFI) – describes your organization’s plan to resolve identified LSC deficiencies.

Beginning in July 2007, accredited organizations will be required to complete the e-Life Safety Assesment which includes an electronic BBI (eBBI) and an electronic PFI (ePFI).

Deficiencies Drawing Sample (click for more)

With Life Safety Code violations topping the list as most frequently cited EC recommendations, health care facilities can’t afford to be without a detailed LSA. TSIG Consulting, a Division of the Greeley Company. (TSIG) provides the best quality LSA in the business today. In fact, we’ve even earned the acclaim of Life Safety Surveyors with such praise as: “the best record of an ongoing progress in work that I’ve ever seen in an LSA.” This is accomplished by an expert team of surveyors, quality drawings, detailed assessments and a final product that is unequalled by our competitors. Our LSA’s include preparation and review of the eBBI, updated smoke and fire walls, validation of compartment requirements, and location defined Plan for Improvements that indicate the cost, funding source and anticipated date of correction. Deficiencies can also be plotted on the drawings in their exact location to assist your organization in the remediation process. This service is offered on a one time effort to create a base line, or a regularly scheduled, periodic update (monthly, quarterly or bi-annually) – which provides true evidence of a “living document.” Let our team of Life Safety Code experts serve as you resource for LSA preparation.

The unique feature of TSIG’s comprehensive LSA is that we provide each client all of the information we collect in electronic format.

  1. Barrier drawings developed in AutoCAD showing the safety features of the building.
  2. Detailed deficiency icons directly placed on the floor plans showing the exact locations of the deficiencies identified during the survey.
  3. PFI items, showing deficiency type, reference to the life safety code, quantity, cost to repair, date identified and a unique number to tie the deficiency from the floor plans to the electronic database.
  4. Determine quickly maintenance items addressable in 45 days period, which can be exclude from the LSA, alleviating the need to manage thousands of items on your LSA.

The above electronic documents are housed on the TSIG LSC website for 24/7 365 day access by any authorized member of your The Joint Commission survey team. Each of TSIG’s clients are provided a customized website for their use at NO COST.

By having the electronic information warehoused in a central & fully accessible location, can minimize the cost of managing the deficiencies. The electronic information can also be quickly integrated into your CMMS (Computerized Maintenance Management Systems) such as TMA or Maximo, MicroMain etc.

Unlike other organizations, TSIG has code consultants, AutoCAD experts, database programmers and web developers all under one roof affording our clients one point of contact and one point of accountability.

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