Dec 12 2017

Office Door Holiday Decorations

Category: Decorations,Doors,Fire Doors,Questions and AnswersBKeyes @ 12:00 am

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 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 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.

Aug 30 2017

Holiday Lights

Category: Decorations,Questions and AnswersBKeyes @ 12:00 am

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

A: Section 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 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.

Jun 01 2017

Combustible Decorations

Category: Decorations,Questions and AnswersBKeyes @ 12:00 am

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 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.

Mar 15 2017

Combustible Decorations

Category: Decorations,Questions and AnswersBKeyes @ 12:00 am

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 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.

Dec 04 2014

Christmas Decorations

Category: Decorations,Questions and AnswersBKeyes @ 6:00 pm

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.

Mar 07 2013

Combustible Decorations

Category: Decorations,Questions and AnswersBKeyes @ 5:00 am

Q: Our corporate office has informed us that we need to remove all artificial plants from the hospital if they do not have a fire rating label attached to the plant. Is an artificial plant considered to be a combustible decoration?

A: Well, it could be. It all depends on who is making the decision that an artificial plant is combustible. Section of the 2000 edition of the Life Safety Code (LSC) says combustible decorations are prohibited in any health care occupancy unless they are flame-retardant. (There are exceptions to this rule, such as photographs or paintings in such limited quantities that a hazard of fire development is not present.) To understand this issue further, section 3.3.29 defines combustible as a material that will ignite and burn when used in the condition it is intended. But, this definition does not define how the test object is to be ignited. Is it by a spark, a lit match, or a butane torch? I presume if you took a torch to the artificial plant you could make it ignite. So, this brings us back to the question: Who is making the decision that an artificial plant is combustible? Since the typical hospital has 5 or 6 different authorities having jurisdiction (AHJs) who enforce the LSC, it only matters what the AHJ believes is combustible, not you or me. Without a label stating the artificial plant is flame-retardant, it may be a hard sell to convince an AHJ the plant is not combustible. In my experience, I have not seen a Joint Commission surveyor or a CMS inspector cite a hospital that has artificial plants as being combustible. It may have happened, but it is not a common finding. Now, decorations made from dried vegetation, such as grape-vine wreaths is an entirely different issue, and those definitely need to be removed.