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 188.8.131.52 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.