Situations leading to an ITL finding: In the environment of care, difficulties within the following important systems and situations can lead to an ITL finding:

• Emergency generator (failure, lack of, poor placement)
• Sprinkler system (failure, inadequate testing and maintenance)
• Fire alarm system (failure, inadequate testing and maintenance)
• Main medical gas panel (failure, not monitored)
• Exits (compromised, lack of, doors not operable)

Responses to an ITL finding: If certain problems with these systems are discovered during survey, your organization may advance to an ITL recommendation. The surveyor will notify your CEO and Joint Commission headquarters of the ITL finding. Your organization will then have up to 72 hours to eliminate the risk completely, or implement interim life safety measures (ILSMs) to abate life safety risks and/or other measures to abate other risks until they can be completely eliminated.