Compliance News: Holiday Decorations

Compliance News:  Holiday Decorations 

by Robert Trotter, BS, MCP and David Stymiest, PE, CHFM, CHSP, FASHE

Many of this newsletter’s readers are regularly confronted with questions concerning holiday decorations. The Joint Commission’s 2012 Hospital Accreditation Standards, Standard LS.02.01.70 EP-1 states: “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)”

In NFPA 101-2000®, paragraph 18/19.7.5.4 states “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

If the local or state authority having jurisdiction has adopted NFPA 101-2012, there are new provisions that apply to decorations. CMS has also indicated its willingness to allow compliance in accordance with the below NFPA 101-2012 wording; however, the organization would have to request a waiver after being cited by CMS. TJC has indicated that organizations may request a traditional equivalency based upon the NFPA 101-2012 decorations wording. Under NFPA 101-2012, 18/19.7.5 Furnishings, Mattresses, and Decorations, paragraph 18/19.7.5.1(b) states “Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located.” In the same section of the 2012 edition, paragraph 18/19.7.5.6 states “Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:

• They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to material to which it is applied.
• The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
• The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Tests for Individual Fuel Packages, using the 20 kW ignition source.
• The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:
• Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 18/19.7.5.6(b), (c), or (d).
• Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
• Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
• Decorations do not exceed 50 percent 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 throughout by an approved automatic sprinkler system in accordance with Section 9.7.

• They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

Appendix A.18/19.7.5.6(4) The percentage of decorations should be measured against the area of the wall or ceiling, not the aggregate total of walls, ceilings, and doors. The door is considered part of the wall.