Oct 14 2015

Combustible Decorations

Category: BlogBKeyes @ 12:00 am
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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.

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Nov 27 2014

OPIYRT

Category: BlogBKeyes @ 6:00 am
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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…

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Nov 21 2014

Christmas Decorations

Category: BlogBKeyes @ 6:00 am
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I received the poem below from Jeff Clouse, Safety Officer at Baptist Health in Lexington, KY. He says it is his way of using humor with the staff of his hospital to stay compliant with the Life Safety Code during the holiday decorating season.

 

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‘Tis about a month before Christmas, and all through the halls,

I endeavor to walk, inspecting the walls.

Looking for wreaths made of twigs, and Santas of paper,

Don’t hide them from me, I will solve the caper.

 

 

Fake snow, pine cones and *gasp* open flames,

Get rid of these things; I will not play games!

Hang nothing from sprinklers, do not block the exits.

If you do, I’ll call Santa then for you…NO PRESENTS!

 

No real trees, no branches, no needles of pine,

Just please help me out, and save all the whine constructive input.

If these things spark up and begin to smoke,

It’ll be hard to get out, and that’s not a joke.

 

Now I’m almost done, but I need to mention,

Bring no cords here, not for extension.

Lights can be used, plugged right in the wall,

But not if they’re hot and stretch across the hall.

 

I’m not being mean; my heart’s not of stone,

But I just can’t leave those fire regulations alone!

And, hey, listen up, don’t be filled with woe,

Fire retardant decorations you can have; that’s the way to go!

 

Great people you are, be safe, that’s the trick,

Keep helping and healing our weary and sick.

I care, too; and that is the reason,

I want us to be safe, this entire holiday season!

+++++++++++++++++++++++++++++++

Do you use something unique to reinforce your decorations policy?

If so, send it to me and I’ll place it in the blog for all to see.

Merry Christmas!

Brad

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Sep 18 2014

Decorations or Communications?

Category: BlogBKeyes @ 6:00 am
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Combustible decorations on bulletin board Web 2The 2000 Life Safety Code, section 18/19.7.5.4 is pretty clear when it states combustible decorations are not permitted in healthcare occupancies unless they are flame-retardant. Flame-retardant decorations can be purchased, but you need to maintain some sort of documentation that the decorations are flame retardant, such as the original packaging. Then it can be presumed that the decorations are acceptable.

At the hospital where I used to work, the maintenance supervisor purchased huge Christmas wreaths for decorating the main lobby. They were made of plastic materials and fortunately for him, he retained the documentation from the manufacturer that they were flame retardant. He actually stapled the documentation to the back of the wreath so it would always be available for review.

If you do not have any documentation that the decorations are flame retardant, then plastic, fabric, paper, and wood-based decorations could very well be cited as combustible decorations. Artificial flowers, whether they are plastic or fabric, can be considered to be combustible if there is no documentation that states otherwise.

Surveyors are not consistent in enforcing this issue. Some surveyors don’t pay much attention to this at all, while other surveyors only cite the more obvious combustible decorations, such as wreaths made from twigs, sticks and grape vines. However, I have seen some survey reports where the surveyors cited all plastic artificial flowers in the hospital.

But what about those bulletin boards frequently found on the nursing units? Many times these bulletin boards are layered with multiple pieces of combustible paper. Are these a violation of the LSC as well? Not necessarily. If the paper that is posted on the bulletin board is truly used for communication (i.e. memos, notices, and other communications), then it is not considered a decoration and therefore is not a violation of section 18/19.7.5.4.

However, many times the bulletin board will be decorated for a particular holiday, or a special event. In these situations, if the bulletin board is decorated with combustible material, then it has crossed the line from communication to decoration, and should be considered for a citation under section 18/19.7.5.4. This is always a judgment call by the surveyor, and the less there is for the surveyor to judge, the better off you will be.

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Dec 06 2012

Christmas Trees in Corridors…

Category: BlogBKeyes @ 11:37 am
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Holiday season is upon us and hospital and nursing home facility managers begin the struggle with decorations that do not meet the Life Safety Code requirements. The most common deficiency with decorations are they are not flame retardant, as required by the Life Safety Code (LSC) according to section 19.7.5.4.

Take the issue with the Christmas tree in the picture to the left. Does it qualify as a flame retardant decoration? I don’t know, and I took the picture yesterday. It is an artificial tree, but I could not find any tag on the tree that offered an explanation that it was flame retardant. I asked the staff if the package it came in said it was flame retardant, and they said the original packaging was thrown away.

So, based on a lack of documentation, the tree does not qualify for section 19.7.5.4, and needs to be removed from the hospital. But there are other issues to consider as well. Section 19.7.5.4 is not limited to just Christmas trees, but all decorations regardless of the season. You may not be able to tell from the picture, but there are combustible items placed on the tree as decorations. Items such as plush stuff toys and paper ornaments. Also, staff had wrapped boxes as decorations and placed them under the tree, which contributes to the overall deficiency.

Then the issue of corridor clearance must be taken under consideration. The tree protrudes into the required width of the corridor. Had the tree qualified for 19.7.5.4 as a combustible decoration that is flame retardant, the tree in the picture is still a problem. It must be placed in an alcove or lobby  where it does not project into the required width of the corridor.

Facility managers and Safety Officers must deal with holiday decorations with tack and politeness, but also with firm decisiveness. The LSC is clear: combustible decoration (that are not flame retardant) are not permitted in healthcare occupancies. The authorities having jurisdiction will hold your organization accountable… so should you.

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