Holiday Decorations in Hospitals

The holiday season is upon us again and that means one thing for hospitals: decorations. From artificial trees and wreaths to paper snowflakes and ornaments hanging from the ceiling, hospitals provide a variety of decorations throughout the holiday season. Despite the memos that are typically circulated throughout hospitals to remind staff of their facility’s policies that limit decorations to only those that are flame retardant, facility managers constantly struggle with staying on top of non-compliant decorations. Thanks to the new categorical waivers permitted by The Centers for Medicare and Medicaid (CMS) and The Joint Commission (TJC), there is more flexibility in restrictions on combustible decorations than have been allowed in the past.

The 2000 Edition of NFPA 101 Section 18/19.7.5.4 states that “combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.” There is an exception for combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. This provision appears to be cut and dry requiring all decorations to be flame-retardant, but leaves it up to the Authority-Having-Jurisdiction (AHJ) to determine if the decorations constitute a fire development hazard. Given the number of AHJs assigned to a hospital coupled with varying interpretations, the most conservative approach has been for facilities to require all decorations to be flame-retardant regardless of size.

On March 9, 2012, the CMS Survey & Certification Group issued memorandum S&C-12-21-LSC which provided instructions for waivers of specific requirements contained in the 2012 Edition of NFPA 101. Section 18/19.7.5 on Furnishings, Mattresses, and Decorations was one of four sections which CMS allowed a waiver to be elected. The provisions of this section were revised and expanded in the 2012 Edition of the Code to make health care occupancies more homelike. Section 18/19.7.5.6 contains the requirements for combustible decorations which was revised as follows:

“Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:

  1. They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
  2. The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
  3. The decoration exhibits a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.
  4. 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 19.7.5.6(B), (C), or (D) [Items 2, 3, 4 below].
    • 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.
  5. They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

In order to utilize the waiver for the combustible decorations, a waiver request was initially required to be processed in the regular fashion with input from the State Survey Agency and final approval by the CMS Regional Office. However, CMS released memo S&C 13-58-LSC on August 30th, 2013 which allowed the waivers specified in S&C 12-21-LSC as well as 8 other provisions to be addressed as categorical waivers.

Facilities that want to take advantage of the combustible decoration waiver to utilize the 2012 NFPA 101 provisions must formally elect to use the waiver and document their election decision. As long as the requirements of the waiver are met, the election is not required to be submitted to CMS for approval nor do you need to wait until cited to utilize the waiver. It should be noted that the use of the waiver must be brought to the attention of the life safety surveyor at the entrance prior to the start of a survey. Additionally, TJC requires the election of the waiver to be identified in the additional notes section of the BBI on the electronic Statement of Conditions.

By electing to utilize the waiver for combustible decorations, hospitals are provided with more leniency regarding their allowance for combustible decorations on walls, ceilings, and non-fire-rated doors. Regardless of whether the waiver is utilized, facility managers and their staff should also keep an eye out for the following issues as they perform their daily rounds:

  1. Decorations should not obstruct or block fire extinguishing or fire alarm equipment such as fire extinguishers or manual pull stations.
  2. Decorations should not be hung from sprinklers, or located adjacent to a sprinkler such that it would obstruct the sprinkler discharge pattern.
  3. Decorations should not be placed on fire rated doors having a required rating or 45-minutes or greater, regardless of their size.
  4. Decorations should not obstruct the required clear width of corridors.