Don’t gift surveyors the ‘low-hanging fruit’ of hazardous holiday decorations

by A.J. Plunkett (

Has your staff started dragging out the holiday decorations yet? Yes, it’s time for you to be Scrooge and remind them that while decorations can be fun for patients they can also pose a deadly fire hazard.

If they don’t pose a fire hazard, tell them to have fun! But if they do, remember that surveyors from The Joint Commission (TJC) and other accreditation organizations won’t let it slide.

TJC surveyors can cite decorations under five—that’s right, five—different Life Safety standards, including two standards related to hospital areas designated ambulatory healthcare occupancies, outpatient clinics, or areas within a leased building where the hospital offers accredited services.

But they all focus on the same basic things, all referenced to NFPA 101-2012 Life Safety Code® or related codes and standards:

  • All fire doors with a ¾-hour rating or more should be free of decorations, except for informational signs applied with adhesive, to protect the integrity of the door to minimize fire, smoke, and heat. (TJC standards LS.02.01.10, LS.03.01.10 and LS.05.01.10.)
  • Any decorations attached directly to the walls, ceiling or non-fire-rated doors cannot exceed 20% of the wall, ceiling or door space in an area that does not have fire sprinklers, or 30% in spaces that are sprinklered smoke compartments, or 50% of spaces inside patient sleeping rooms that “do not exceed four people in sprinklered smoke compartments. (For full text, refer to NFPA 101-2012: 18/” (TJC standards LS.02.01.70).
  • And the hospital “prohibits all combustible decorations unless they meet the criteria of NFPA 101-2012: 20/” (TJC’s LS.03.01.70)

Combustibles not allowed

Hospital fire safety experts say that last point on combustibles include, but isn’t limited to, artificial snow, or decorations like crepe paper in any quantity, or artificial trees unless they are labeled or otherwise documented to be flame retardant or flame resistant.

Your hospital decorations policy – and yes, you should have one that states expectations, including when the decorations should come down— should make it clear that trees or large decorations can’t be placed in hallways or obstruct doors.

So those oh-so-fun images that go around of the pumpkin mother having little pumpkin babies on a gurney in the hospital isn’t so fun if it’s within the path of egress — or the eyesight of a wandering surveyor.

Also make sure your hospital’s electrical or safety department approves lights or other electrical equipment, including extension cords, because they must be for indoor use only and be UL or FM approved.

Finally, make sure decorations are NOT strung from fire sprinkler heads or where they can obstruct exit or other safety signs.

For more tips, go to

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Have you successfully survived a survey during a holiday season with decorations around? And if so, do you have photos you’d like to share with your colleagues of how you did it?

Alternatively, do you have photos of decorations that didn’t pass the compliance muster?

Share your photos with us, and we will publish the highlights in future issues of Inside Accreditation and Quality and Healthcare Safety Leader. Plus, everyone who contributes will get a discount code from AQCC for $25 for use on HCPro’s HCMarketplace.**

Please send your photos, with any explanations of content, to IAQ editor A.J. Plunkett at

Editor’s note: **This promotion is subject to all applicable laws and is void where prohibited. Discount is valid on new orders only, one use per person. Discount excludes 2021 & 2022 ACDIS Pocket Guide, 2021 & 2022 JustCoding Pocket Guide, 2021 & 2022 ACDIS Outpatient Pocket Guide, ACDIS PRO, JustCoding PRO, ACDIS Outpatient PRO, Physician PRO, all boot camps, and all conferences. Promotion expires on December 31, 2021. By submitting your images, you agree to allow AQCC and HCPro to use and publish them in any legal way and waive any right to royalties or other compensation arising or related to the use of the images.