How Safe Are Your Decorations?

Tips and Suggestions for Decorating Your Facility Safely and Within Guidelines

october 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

As many across the globe begin to look forward to holiday celebrations, it is important to consider the risks associated with decorating. Although decorating in the healthcare setting is not forbidden, it is important to evaluate decorations for potential safety risks prior to displaying them.


When it comes to celebrating holidays, spirits are high. Many employees like to participate in decorating events and there is a lot to be said about how a change of scenery can significantly boost the morale of patients as well as healthcare providers.  


While we love and support the spirit of the holiday season, in our experience there have been many occasions in which we have had to address decorations due to safety risks associated with the type or location of celebratory decorations. 


Here are a few tips to keep your facility safe and compliant for any holiday you and your team members choose to celebrate: 

  • Decorations should not interfere with the ability to open and close doors. 
  • Combustible decorations should be kept to a minimum 
  • Keep decorative coverings over windows and doors to a minimum 
  • Do not hang decorations from sprinkler heads. 
  • Decorations should be flame resistant. Manufacturer recommendations (MFRs) should be followed if decorations are covered in an approved fire-resistant coating. If re-application of such a material is recommended, the facility must provide documentation that re-application has been done according to the MFR (NFPA 701). 
  • Decorations shall 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. 
  • 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. 
  • 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 supervised automatic sprinkler system. 
  • The decorations exhibit a heat release rate not exceeding 100 kW when treated in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20-kW ignition source. 
  • Avoid the use of unapproved electrical power strips.
List of Disaster

Education
 

Additional considerations for decorating should include developing a policy that addresses decoration for your facility. Be sure to incorporate guidance or restrictions based on Life Safety, Environment of Care and NFPA standards. It is always a good idea to include your facilities’ plant ops and bio-med technicians when planning holiday or celebratory decorating. They can provide valuable input on restrictions and identify issues that may lead to potential safety risks in your facility. 


 From all of us here at HCE, we would like to wish you a happy and healthy holiday season. 


References: 

NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. NFPA 289 Standard Method of Fire Test for Individual Fuel Packages 

https://www.nfpa.org/codes-and-standards  

 TJC LS 02.01.10- Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. https://www.jointcommission.org/search/#q=02.01.10&t=_Tab_All&sort=relevancy&f:_SitesOrganizations=[The%20Joint%20Commission  
 
HCE is Here to Help
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that all healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.


 Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit Our Website   to see a full list of the services that we provide. Contact us today at +1 (800) 813-7117 for a free initial consultation.


Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Woman sitting at a desk, holding her shoulder while working on a laptop in a bright room.

Safe Patient Handling, Mobility, and Workplace Safety: Merging OSHA Mandates with CMS Quality Outcomes

June 4, 2026
OSHA's General Duty Clause and Ergonomic Risks Under Section 5(a)(1) of the Occupational Safety and Health Act (the General Duty Clause), healthcare employers are legally required to provide a work environment free from recognized hazards that cause or are likely to cause death or serious physical harm. Manual patient lifting, transferring, and repositioning represent significant ergonomic hazards. OSHA actively inspects healthcare systems for musculoskeletal disorders (MSDs) and mandates that hospitals implement engineered control solutions, such as ceiling lifts, sit-to-stand devices, and friction-reducing slide sheets.

Mitigating Electrical and Fire Risks in High-Acuity Care: NFPA 99 & Accrediting Body Imperatives

May 5, 2026
The Technical Baseline: NFPA 99 Health Care Facilities Code NFPA 99 (2012 Edition, as mandated by CMS) establishes risk-based categories for electrical and gas systems based on the risk to patients. Category 1 spaces are those where procedures are performed that could result in major injury or death if utility systems fail. Under Chapter 6 (Electrical Systems), facilities must maintain isolated power systems (IPS) and line isolation monitors (LIM) in wet procedure locations to protect patients against electrical shock.  Survey Vulnerabilities: CIHQ and Joint Commission Directives During surveys, both TJC and CIHQ closely inspect the testing logs for these specialized electrical environments. TJC Standard EC.02.05.01 requires facilities to manage utility risks, specifically focusing on the routine inspection of ground- fault circuit interrupters (GFCIs) and the regular calibration of LIM alarms. CIHQ surveyors frequently evaluate surgical staff on their understanding of the LIM panel: if an alarm sounds, do clinicians know that it signifies a critical loss of electrical isolation that could cause patient harm if a second fault occurs? OSHA 29 CFR § 1910 Subpart S Alignment While NFPA 99 protects the patient, OSHA Subpart S (Electrical Safety) safeguards the clinical staff operating the machinery. Employers must ensure all electrical medical devices are free from recognized hazards. Exposed wiring, unapproved extension cords, or failing to lock out/tag out malfunctioning medical hardware violates OSHA standards and places both employees and patients at immediate risk.
Red fire alarm box on a white hallway wall with a long corridor in the background

The Intersection of Clinical Quality & Environment of Care: Aligning CMS, AOs, and NFPA 101

April 4, 2026
CMS Conditions of Participation (CoPs) and the Unified Focus The Centers for Medicare & Medicaid Services (CMS) establishes the baseline for safety through the Conditions of Participation (CoPs). Under 42 CFR § 482.41 (Physical Environment), hospitals must ensure that the physical plant is constructed, arranged, and maintained to secure the safety of patients. CMS holds leadership strictly accountable for ensuring that life safety deficiencies do not interfere with clinical intervention. When a surveyor enters a facility, they cross- reference the clinical patient logs with facility maintenance schedules to ensure environment-driven risks—such as positive/negative pressure room failures—did not impact immunosuppressed patients. Accrediting Bodies: CIHQ, Joint Commission and Other Aos’ Interventions Accrediting organizations like The Joint Commission (TJC) and the Center for Improvement in Healthcare Quality (CIHQ) act as the enforcement arms for CMS via deemed status. TJC’s Environment of Care (EC) and Life Safety (LS) chapters explicitly detail how physical space directly impacts clinical delivery. For instance, TJC Standard EC.02.03.05 requires hospitals to maintain and test fire protection and suppression systems, mapping directly back to Life Safety Code compliance. Simultaneously, CIHQ’s structural surveys place massive emphasis on a unified environment. CIHQ approaches physical plant standards as a direct extension of standard clinical operations. They emphasize that blocked egress corridors or improperly stored medical equipment don't just constitute technical facility violations; they are direct barriers to rapid code-blue response and emergency patient evacuations.