Christmas Garland

Q: We are a fully sprinkled hospital. Is it permissible to hang Christmas garland from the ceiling, as long as we stay away from sprinkler heads and abide by the 30% rule? Does the garland need to be fire-retardant?

A: According to section 19.7.5.6 (4) of the 2012 Life Safety Code, combustible decorations such as photographs, paintings, and other art are permitted as long as they are attached directly to the walls, ceiling, and non-fire-rated doors provided the following is complied with:

  • Decorations on non-fire-rated doors not interfere with the operation of any required latching of the door;
  • Decorations do not exceed 20% of the wall, ceiling and door areas inside any room or space of a smoke compartment that is not protected with sprinklers;
  • Decorations do not exceed 30% of the wall, ceiling and door areas inside any room or space of a smoke compartment that is protected with sprinklers;
  • Decorations do not exceed 50% of the wall, ceiling and door areas inside patient sleeping rooms having a capacity not exceeding four persons in a smoke compartment that is protected with sprinklers;

According to the Annex section A.19.7.5.6 (4):

  • The percentage of decorations should be measured against the area of any wall or ceiling where the decorations are located, and not the aggregate total of all walls, ceilings, and doors;
  • The decorations must be located such that they do not interfere with the operation of any doors, sprinkler, smoke detector, or any other life safety equipment;
  • The term “Other art” might include hanging objects or three-dimensional items.

While the Annex section of the Life Safety Code is not considered to be part of the requirements of the enforceable code, it is considered explanatory material intended for informational purposes only. It provides guidance to the readers of the LSC on what the reasoning was by the Technical Committee when that section of the code was written. Most authorities having jurisdiction (AHJ) follow what the Annex says but they are not under any obligation to do so.

So, let’s break this down into steps:

  1. Garland is not the same as a photograph or a painting, but may likely comply with the definition of ‘Other art’ as explained in the Annex.
  2. Some surveyors may believe that garland that is suspended from the ceiling and allowed to ‘droop’ may be considered to not be attached directly to the ceiling as section 19.7.5.6 (4) requires.
  3. Non-fire-retardant garland attached directly to the ceiling appears to be permitted based on what the Annex says, provided it does not take up more than 30% of the ceiling space from which it is attached.
  4. The garland cannot interfere with the sprinklers so you would have to comply with section 8.6.5.1.2 and 8.6.5.2.1.3 of NFPA 13-2010 for ceiling mounted obstructions. Quite honestly, this will be pretty difficult to meet with hanging garland in a corridor.

The problem with all of this is not every surveyor will agree that garland qualifies as ‘Other art’. You can show them what the Annex says, but remember that they are not under any obligation to comply with what the Annex says. Most AHJs do, but you may get a rouge surveyor who simply does not agree and will cite it if they observe it. And, as stated above, it is very challenging to suspend something like garland from the ceiling in a corridor and not interfere with the sprinklers. Make sure you follow NFPA 13-2010 carefully.

All in all, it would be easier to not permit it in your facility.

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Cabinets in a Corridor – Part 1

Q: It appears that the LSC allows up to 50 square feet of unprotected storage but also includes language that suggests it may need to be protected in accordance with 8.7 depending on the level of hazard. It is my experience that storage in a nurse station (even if combustible) is acceptable because it is located in a normally monitored and occupied area. But what about PPE or patient information storage in closed cabinets away from a nurse station? Would this decision be left to the AHJ?

A: In a scenario as you described, I believe it is all about the cabinet and doors. Is the cabinet mounted in such a way that it projects into the corridor by more than 4 inches? If so, that would be a problem. If the doors to the cabinet were to be left open, would the doors project into the corridor more than 4 inches? If so, that too would be a problem. As long as the square footage of the stored items is less than 50 square feet, I don’t see a problem. The cabinet door would not have to meet the requirements for corridor door (i.e. resist the passage of smoke, positive latching hardware, 1¾-inch thickness, solid bonded wood core) as long as the LS drawings delineated that the corridor wall ran behind the cabinet.

Strange Observations – Wall Sconce Projection

Continuing in a series of strange things that I have seen while consulting at hospitals…

Do you ever think about your corridor wall sconce light fixtures projecting more than 4-inches into the corridor…?

I do.

[Hey… AH: I made that change that you suggested.]

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Door Frames

Q: I had an independent Life Safety inspection and during the inspection the inspector cited me for my 2-hour fire door frames not having a fire rating visible. I explained that we went to a fire rated continuous hinge on these doors that covered the labels. He said that that was not enough, he needed to see a label. Should I remove each hinge and take a picture of the fire rating labels?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

A: This topic has come up before, and I asked some AHJs about it since the answer is not found in the codes and standards.  The consensus was that the label should be documented with photos before the hinges are installed – close-up photos to show what is written on the label, and wider photos to show the location of the door.

I’m sure it’s a pain to get this documentation now, but I think that’s the only way to do it for a retrofit situation unless you want to have the doors relabeled.  For new doors and frames, the labels can be applied in another location – on the frame head, and for the doors – either on top or on the lock edge.

Patient Therapy Artwork: Decorations vs. Communication

Q: You once said this regarding bulletin board decorations:

If the bulletin board is decorated then yes; it is counted as decorations. But if the bulletin board is simply communication documents, then they are not decorations (even if they are combustible) and they are not counted in the wall surface calculations for decorations.

I would like to add a twist to this topic. We are a psychiatric hospital and the patients use a therapy activity for painting or drawing. They like to post their art work on the wall of the day-room with scotch tape. I interpret their art as a function of the hospital and as form of therapy and communication. I do not consider it decorations. Does this change your answer?

A: No. If I was surveying and saw what you described, I would still be inclined to consider the patient therapy artwork as decorations. Now, if you have documentation from medical and clinical experts in the form of a policy that confirms the patient therapy artwork is not decoration, but a clinical form of communication, I wound yield to those subject matter experts on this issue, and allow it to be communication.

But with the changes in the 2012 LSC on what they consider decorations, as long as you don’t exceed the 20% or 30% surface area of the walls and ceilings, I don’t think it will be a problem.

Clean Waste Containers

Q: I have a question regarding recycling containers referenced in section 19.7.5.7.2 of the 2012 LSC. It outlines the requirements for clean recycling and patient records awaiting destruction.  Do the requirements for FM Approval (or equivalent) apply to containers less than 32 gallons or just for containers 32 to 96 gallons? The way the code reads I originally thought it was for any recycling container regardless of capacity but the way the code reads it has me thinking.

A: Section 19.7.5.7.2 of the 2012 LSC states containers used solely for clean recyclables do not have to be stored in a hazardous room, provided it meets all of the following:

  • Containers do not 96 gallon capacity, maximum
  • Containers that do exceed 96 gallon capacity must be stored in a hazardous room
  • If stored in a hazardous room, the capacity of the container is not limited
  • Containers must meet FM Approval 6921 requirements, or equal.

So, I would say the requirement for FM Approval 6921 applies to containers with capacities between 32 and 96 gallons. Because if the container is less than 32 gallons capacity, it is permitted to be stored outside of a hazardous room (think of your wastebasket in your office) and not meet the requirements of FM Approval 6921. But a container over 32 gallons capacity is not allowed to be stored outside of a hazardous room unless it meets the requirements of 19.7.5.7.2. And, all containers over 96 gallons capacity must be stored in a hazardous room regardless if they are FM Approval 6921 compliant.

Keyes Life Safety Boot Camp – February 7 & 8, 2019

Understand practical applications of the NFPA 101 Life Safety Code®! Learn from a Life Safety surveyor on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Compliance One.

Date: February 7 & 8, 2019

Location: The Boot Camp will be held at Jackson-Madison County General Hospital in the J. Walter Barnes Conference Center, located at 620 Skyline Drive, Jackson, TN 38301.

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Strange Observations • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenter:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; and former Joint Commission LS surveyor.

Cost: Early-bird registration is $789.00 per participant and is valid through December 31, 2018. Starting January 1, 2019 the rate is $889.00 per attendee.

Includes: Workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel: The designated hotel to stay is the Doubletree Hotel, 1770 Highway 45 Bypass, Jackson TN 38305. Use Group Code ‘LSB’ for discount pricing. Transportation between hotel and Jackson-Madison County General hospital will be provided.

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on January 15, 2019. To register, go to https://complianceonegroup.com/westtennesseehealthcare/

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or January 15, 2019

Cancellation Policy: Due to limited seating, you may cancel your registration up to 2-weeks prior to the scheduled boot camp. Cancellations will incur a $25.00 fee.

Bring your own copy of the 2012 Life Safety Code!

Exclusively sponsored by:

Fire Pins

Q: I have a concern regarding the use of fire pins in fire rated door leaves: Since the latching feature of these devices is not testable (that I’m aware of, anyway), and as these doors are prone to abuse and sometimes require adjustment for clearance issues and so forth, how do we ensure the alignment of the fire pin assembly when adjustments are made or even during normal expansion/contraction due to temperature/humidity changes?

(The reply for this question comes from Lori Greene, Manager of Codes & Resources at Allegion. Visit Lori’s website on doors and hardware at www.idighardware.com)

 A: You’re right – there’s no way to test the pin.  But the pin and the hole that it will project into (typically filled with a plastic cap) should be visible on the door edge so you can ensure that they’re aligned.  On most pins there is a fair amount of tolerance so the alignment doesn’t have to be perfect.  Since the pins operate only when there’s a fire, and only when the temperature reaches >1000 degrees in the vicinity of the door (approx. 450 degrees at the pin), only a very small percentage of the pins will ever be activated.  The pin doesn’t have much of an impact on life safety – by the time the pin projects, it’s mostly about compartmentalizing the building and protecting property.