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As we prepare for the Holidays and our upcoming Joint Commission survey, it is important that all departments adhere to the UNC Health Care Decoration Policy. Failure to do say may result in violations of Joint Commission standards.

We want to provide a warm and appealing environment for its patients, visitors, and staff while at the same time providing a safe environment. It is important that we recognize that safety of our patients, personnel, and the general public is of vital concern. Please keep the following in mind when decorating and review the full policy here:

  • NFPA Life Safety Code® limits the amount of combustible materials that can be displayed on a wall to 10% of the wall. Interior walls and ceiling finishes cannot have more than 10 percent of the aggregate wall and ceiling areas of any room or space covered in combustible materials. This includes paintings and photographs. Any decorations beyond the initial 10% shall be flame retardant and documentation shall support the flame resistance of decorative items and shall be maintained by the department displaying the items.
  • No items can be placed on doors. This includes mail pockets or bins and wreaths or other decorative items. All doors must remain free of items that could interfere with the clear width egress requirements for the door and that would affect the door’s fire rating or ability to close. Only informational signage is allowed to be posted on doors after prior approval by PED or EH&S.
  • Electric lights such as electric candles, lights in strands and lights used in other decorative items, shall be prohibited except for the Christmas trees which may be displayed in the main lobbies and in the Gift Shops of the UNC Hospitals by Volunteer Services.
  • Lighted natural candles, open flames, or spark-producing devices of any type are strictly prohibited with the exception of the use of candles in the chapels located on the Ground Floor NC Cancer Hospital, 1st Floor NC Memorial Hospital, and Ground Floor NC Children’s Hospital which must be under the direct supervision of a Hospital chaplain. The use of candles is not allowed in the chapel located on the 5th floor of Patient Support Tower next to the Burn Center. The use of candles is not allowed in any other locations for any purpose, religious or otherwise. Persons on oxygen will not be allowed in the chapel while candles are burning.
  • Natural trees (live or cut), roping, wreaths, and similar items made from natural materials shall not be placed or used in UNC Health Care facilities.
  • Artificial trees and wreaths shall be flame-retardant and be labeled as such by an approved testing organization, such as Underwriters Laboratory. Documentation shall support the flame resistance of decorative items and shall be maintained by the department displaying the items. Spray-on flame-retardants are prohibited.
  • Artificial trees and other decorations that are supported from a stand device on the floor shall be mounted to be stable without the additional support of external fixtures, wires, or stays. Decorative items placed on or within artificial trees or wreaths shall be securely fastened to avoid becoming a hazard through falling or breaking.
  • Artificial trees cannot be displayed within an exit access corridor.
  • Decorations shall not be suspended from the ceiling, ceiling tiles or ceiling fixtures (including sprinkler heads or smoke detectors), as they constitute a fire hazard.
  • Do not place decorations within 18 inches of a sprinkler head.
  • Ensure that decorations do not pose a trip hazard or otherwise provide an obstruction to walking or sitting.
  • Ensure that all corridors and hallways, including those inside work areas are open, clear, and provide the required unobstructed egress.
  • Ensure that decorations do not obstruct lights, light switches or electrical outlets or obstruct or interfere with passage on stairwells, hallways, and corridors.
  • Decorations must be at least 36” away from portable fire extinguishers, exit signs, pull stations, fire alarm strobes, fire hose cabinets, and smoke detectors.
  • Ensure that decorations do not obstruct or interfere with any line of sight visibility of approved exit signs and exit routes.
  • Ensure that decorations are not accessible to young children as much as possible. Ensure that decorations are not breakable or edible. Decorations should not be secured with hooks that could be a choking hazard.
  • Decorative items placed on walls shall be secured against becoming dislodged, falling from the support, or becoming a hazard to nearby persons.
  • Decorations shall not be placed within three (3) feet of electrical equipment or other heat producing sources.
  • Decorations shall not be taped, stapled or otherwise attached to painted surfaces per Plant Engineering policy.