Christmas Decorations – Part 2

Q: I enjoyed your recent post regarding Christmas decorations. However, can you please simplify for me the rules on Christmas decorations in hospitals? The percentages are a little confusing, I think. Thank you very much.

A: Not to be a smarty-pants, but here is a simple interpretation:

DON’T ALLOW ANY DECORATIONS!

I know that would not be very popular, but that would be the safest and easiest. But here is another way of looking at decorations:

  • If your building is fully sprinklered, the LSC permits up to 30% of the walls and ceilings to be covered with combustible decorations.
  • Combustible decorations that are not mounted to the walls or ceilings are not permitted (i.e. Christmas trees)
  • Decorations that are not attached to the walls or ceilings must be flame retardant
  • You cannot use an extension cord (or a power strip) to power electrical decorations
  • All electrical decorations must be UL listed

Christmas Decorations

Q: I notified our administration that Christmas decorations are basically forbidden in a healthcare occupancy. We do have a few floors that are business occupancy and they were wondering what the restrictions of decorating are within a business occupancy (we are fully sprinkled). I do not see anything about this in the Life Safety Code pertaining to business or mixed occupancy. Do you mind sharing any advice?

A: Well…. Actually, the Life Safety Code does address this issue and there is a difference between occupancies. Section 19.7.5.6 of the 2012 LSC prohibits combustible decorations in a Healthcare Occupancy (i.e. hospital), with the exception (and this is a rather generous exception) of wall and/or ceiling mounted combustible decorations that cover 20% of the wall and ceiling surface in non-sprinklered smoke compartments, 30% of the wall and ceiling surface in a sprinklered smoke compartment, and 50% of the wall and ceiling surface in patient sleeping rooms that have a capacity of no more than 4 persons in smoke compartments that are full protected with sprinklers.

In chapter 39 for Business Occupancies, there are no restrictions, so decorations are not restricted. However, you cannot have non-UL listed electrical decorations, and the National Electrical Code prevents you from using extension cords to power electrical decorations.

Patient Room Decorations

Q: Where does “Homelike Environment” end and fire safety begin? We have a resident who likes to push-pin everything she makes in activities to her wall. On a recent Life/Safety visit, the surveyor noted that she had “too much stuff” on her walls and that it was a “fire hazard”. We are supposed to encourage “homelike” and “Individualized Care”, then we are told that we have to tell the resident that they cannot decorate their “home” as they desire. I know there has to be a balance, but the items do not impede entrance nor egress to the room and, while there are a lot of items, high and low, they are not on top of one another nor sticking out more than 3 or 4 inches from the wall. One might consider them to be “cluttered”, however, they are not on the floor. Also, he said that everything from pictures to wreaths to whatever has to be “flame retardant”. Are we to spray everything that a family brings in from home?

A: By the sound of your comments, it appears to me that you are referring to a nursing home environment. I am very empathetic to your problem as I understand that CMS state agencies want you to create a “home-like” environment for long-term care patients, but yet, you are required to comply with the 2012 edition of the Life Safety Code.

However, there is some relief available to you on this subject. Since CMS adopted the 2012 edition of the Life Safety Code effective July 5, 2016, section 19.7.5.6 changes how decorations may be displayed in the patient’s room:

  • Combustible decorations are permitted to be attached to walls, ceiling and non-fire rated doors as long as the decorations do not interfere with the operation of the doors
  • Combustible decorations may not exceed 20 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is not fully protected by sprinklers
  • Combustible decorations may not exceed 30 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is fully protected by sprinklers
  • Combustible decorations may not exceed 50 percent of the wall, door and ceiling areas inside patient sleeping rooms having a capacity of no more than 4 patients, in a smoke compartment that is fully protected by sprinklers

I don’t know if the decorations covering the walls that the surveyor saw were within the above limitations, but I would think your organization could calculate the square footage of the decorations and ensure it stays within the limits.

Office Door Holiday Decorations

Q: Staff members at our behavioral healthcare facility enjoy decorating their corridor office doors (business occupancy, 20-minute fire-rated doors, multiple floors) with wrapping paper, bows, etc. affixed with scotch tape for the holidays. Are there specific prohibitions against this? We don’t want to be a Grinch unless necessary. thanks!

A: Section 7.1.10.2.1 of the 2012 LSC says decorations cannot obstruct the function of the door or the visibility of the egress components. So, the decorations cannot obstruct the door in any way.

Section 4.1.4.1 of NFPA 80-2010 says signage on fire-rated doors cannot be more than 5% of the door surface. Now decorations may not be considered signage by most individuals, but the intent is to keep the fire-load on the door to a minimum so it can function properly in the event of a fire. I can see where a surveyor would have a serious issue with decorating fire-rated doors with wrapping paper and bows, because it adds fuel to the door that was not present during the UL testing of the doors.

Sorry, but I suggest you be the Grinch and tell them to remove wrapping paper and bows from the fire-rated doors.

Holiday Lights

Q: What (if any) is the regulation on the governance of holiday lights in a healthcare occupancy?

A: Section 19.7.5.6 of the 2012 LSC only address combustible decorations, and does not address holiday lights. You didn’t say but it is presumed that the holiday lights are not combustible. The Life Safety Code does not address electrical decorations. However, the 2012 Life Safety Code does say under section 4.6.1.2 that any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

Your accreditation organization and likely your state agency that surveys on behalf of CMS, have standards that address electrical safety, or building safety. If you use holiday lights in an unsafe manner, then a surveyor can cite you for non-compliance with their general safety standards.

Often times these AHJs will expect you to have a policy on the safe use of holiday lights in your facility, that way they can hold you accountable to what your policy says. So if you have a policy on how you expect your staff to use holiday lights, then that will likely suffice.

Combustible Decorations

Q: Must combustible decorations have a flame-retardant coating and sticker affixed (or documentation provided) as long as the total area does not exceed the 30% wall surface threshold for fully-sprinklered smoke compartments?

A: According to 19.7.5.6 of the 2012 LSC, combustible decorations are prohibited in healthcare occupancies unless they meet one of the 5 listed criteria. The 30% wall and ceiling allowance is one of those five exceptions. So, no; the combustible decorations do not have to be flame retardant or a sticker affixed as long as the total area does not exceed the 30% for fully sprinkler smoke compartment.

Combustible Decorations

Q: We have a large wall 15 ft. x 12 ft. in our public cafeteria in the hospital that gets decorated with a different theme every quarter. This was started early this year and everyone seems to love it. Materials used varies from papers, pictures, plastics, cardboard, etc. Should this be a concern or a violation of the Life Safety Code?

A: Yes… it should be a concern. Section 19.7.5.6 of the 2012 LSC discusses the limitations of combustible decorations on wall and ceiling surfaces. You are only allowed to cover 20% of the wall surface in non-sprinklered areas, and only 30% in sprinklered areas. Keep an eye on the quantity of wall surface covered to make sure they do not cover more than the allowed amount.

Combustible Decorations

images[5]Combustible decorations have been prohibited in healthcare occupancies (i.e. hospitals, nursing homes) for decades; however decorations that are flame-retardant are permitted, according to section 19.7.5.4 of the 2000 Life Safety Code. But managing decorations and keeping track of the flame-retardant documentation can be a challenge for most facility managers.

Staff like to brighten their office or work environment by bringing in decorations they find from home. Unfortunately, these decorations often times do not meet the requirements for fire-retardant, as required by the Life Safety Code. But even flame-retardant decorations can get you in trouble as mentioned in the following note I received from Chip Hicks, the safety officer for Baptist Health System in Montgomery, AL.

Brad: I want to share a recent Joint Commission survey experience. We have a three hospital system with a pretty robust decorating policy. With that said we were surveyed last week and during the LS/EC building tour the LS specialist came across some decorations in one of our units. He asked for clarification on combustibility which we provided. After looking at the documentation he asked me to remove some of the material, find him a lighter and a place outside to perform a test. We went outside and tried to light the decorations and to my surprise both pieces of material erupted in flames. One piece burned so quickly I had to drop it to keep from burning myself. Anyway, I just wanted to share that surveyors are looking more closely at decorations and performing these tests. Frankly I’m glad he did as it was an eye opener for me and I will no longer trust any flame retardant or flame resistant documentation. As you can imagine we are in the midst of evaluating our decorating policy.

When I was a surveyor for Joint Commission, we were not permitted to conduct such tests, due to the liability involved. Who knows what fires I could have started with a simple decoration test? I suspect the official position of the accreditor is they still do not permit them, but when the surveyor is onsite and wants to do a test like that… who’s going to stop him?

As Chip mentioned, he was glad that the surveyor brought to his attention the combustibility of “flame retardant” decorations.

Christmas Decorations

I have received quite a few questions concerning combustible decorations this season and thought I would run this special Q&A today…

 

Fire Retardant Spray Web 2

Q: My administration is decorating our hospital lobby and has purchased some decorations that do not have a flame retardant rating or certificate. I have informed them that they are in violation of the Life Safety Code. They have found product that can be sprayed on the decorations to make them meet code. I am not convinced that this meets the intent of the code. They claim it meets the requirements of NFPA 701. Have you heard of this product and if applied will I be compliant with code?

A: Yes, I am familiar with this product, and I do not have any problems with the safety of its proper use. However, how are you going to prove to a surveyor that the decorations have been treated with the flame retardant? Once it is applied, it dries clear and there is no physical evidence that the product has been applied.

The typical surveyor wants proof that the flame retardant has been applied. Work orders identifying the decoration in detail, along with its location and the date of application, may be acceptable. A photograph of the product being applied is even more effective, but you would have to photograph every piece of decoration that it is applied to. Documenting (writing) on the decoration the date of the last application and the work order number may also be effective. The problem is it becomes a nightmare trying to document every decoration. And what about the decorations that may have been missed? How can you tell if it was treated or not?

Can you meet the intent of the Life Safety Code with this flame retardant spray-on solution? Yes… but it is not easy to document.

OPIYRT

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The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that performs surveys on behalf of CMS.

I recently read your article on Decorations. I thought the advice was really good information. I was contacted by a facility not too long ago that asked me if a large, homemade tapestry brought to a resident’s room would need to be fire retardant if it was hung up. The question from the engineer was valid as it was to be hung as a “decoration”, was made of flammable material and the family wanted to hang it in the corridor. He wanted to know if it should be fire-treated. His argument was focused on not allowing the family to bring it in at all, mostly because he found it objectionable. I related to him the code; how it could be both stringently and loosely interpreted and suggested, as you pointed out, to err on the side of caution and either treat it or suggest to the family it wasn’t allowed by the standard. The main issue was that the family wanted to hang it in the corridor, which I pointed out could potentially affect safe egress. I then asked him what he felt would be a surveyor’s opinion if this same decoration was hung inside the room, or used as a blanket.

I pointed out that many times I am in a facility where the family has brought in a blanket, or other homemade decoration to make their loved ones feel at home during their stay, or possibly their final hours. I stated I view those items based upon the possible risk, and the intent of the standard. More often than not I find they pose no greater risk to the facility’s other occupants than the same person’s bathrobe knitted by their aunt (when solely used or displayed inside their respective room).

Point being that speaking for myself, I view it solely based on each individual situation: If the facility is providing it and it poses a possible risk to the safe housing or evacuation of all occupants, I will look at that risk and evaluate the issue, citing it if it is apparent and substantiated. I will not unnecessarily burden a resident, patient, client, family or staff member for the purpose of removing something that falls within the letter of the rule for the sole purpose of demonstrating that rule. As always, “it depends”.

I find it refreshing that a state surveyor would have compassion and evaluate issues on a case by case basis. But if this is not done carefully, it can lead to inconsistent interpretations and cause problems when AHJs do not agree on the same issue.

I think hospitals have too many AHJs conducting inspections and surveys in their facility, as it often leads to differences of opinion on how an issue should be interpreted by the AHJs. Ultimately, the hospitals often have to ‘do-over’ a construction project because they receive poor advice from an architect, or an incorrect interpretation from an AHJ.

No wonder healthcare costs so much…