With the implementation of the Centers for Medicare and Medicaid Services (CMS) Requirements of Participation (RoP) came new focus on skilled nursing centers’ smoking policies and procedures. CMS gives direction to the regulators to focus on areas that have resulted in actual harm. One example of actual harm was of a resident smoking in his room while he was receiving oxygen which caused a facility fire that killed two and injured 14. In another example, a resident went alone to a smoking area directly from the dining room with her clothing protector still intact, and the clothing protector caught on fire.
Each center should clearly define their smoking policies and inform staff and residents prior to admission or hiring. Communication and education of the policy is the key to safety and adherence to guidelines.
Skilled nursing centers should follow NFPA 101 at 19.7.4 and K-741 guidelines when developing and implementing their smoking policies. K-741 require that smoking regulations shall be adopted and shall include not less than the following provisions:
- Smoking shall be prohibited in any room, ward or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read “NO SMOKING” or shall be posted with the international symbol for no smoking.
- In health care occupancies where smoking is prohibited, and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
- Smoking by patients classified as not responsible shall be prohibited.
- The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
- Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
- Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
In addition to K-741, the center should follow interpretive guidance for F926 to ensure all regulations are met when developing and implementing smoking policies. The interpretive guidelines require that the surveyor review the facility smoking policies to determine if they have been developed and are being implemented.
Interpretive guidance for F926 requires that when the surveyor is interviewing residents who smoke, she is to ask the residents how the center permits them to smoke. Make sure those residents who smoke clearly understand your center’s proper policies and procedures.
The interpretive guidelines for F689 has a section for Resident Smoking and states the center must assess the resident’s capabilities and deficits to determine whether supervision is required. If it is determined that the resident needs assistance and supervision for smoking, the center must include this information in the resident’s care plan and then review and revise the plan as needed. The center may designate certain areas for resident smoking and must ensure that precautions are taken for the resident’s individual safety, as well as the safety of others in the center. Such precautions may include smoking only in designated areas, supervising residents whose assessment and care plan indicate a need for it and limiting the accessibility of matches and lighters by residents who need supervision when smoking for safety reasons. Smoking by residents when oxygen is in use is prohibited, and any smoking by others near flammable substances is also problematic.
In addition to the above regulations, there are several factors centers should consider regarding residents who desire to smoke. Listed below are some of these factors. Please note the below list is not all-inclusive as each situation is different and may vary according to resident and center characteristics.
- Center policy –The smoking policy should be written clearly without ambiguity and be communicated to employees, residents, staff and visitors. While safety should be a primary consideration with regards to developing an effective smoking policy, resident rights should also be protected to the greatest extent possible.
- Cognitive status and supervision – In many cases involving fires in skilled nursing centers, the issue of adequate supervision is most often cited as the reason for smoking-related fires. Residents with deficits or recent changes in memory and/or judgement need to be assessed to determine how much supervision they will require when smoking. Residents with cognitive deficits will typically require more supervision when smoking than residents who do not have cognitive deficits. In addition, residents who are cognitively intact and, on the surface, appear they can smoke with little supervision may require more supervision if they are prone to provide smoking materials to residents who would typically require a high level of supervision when smoking. Supervision may also include evaluation of whether the resident can retain their own cigars, cigarettes, matches, lighters, etc., or if the center should retain these items to distribute for use upon request. If the resident is deemed safe to smoke alone and retain smoking materials, the materials must be kept from residents who would not be safe, such as in a fireproof lock box.
- Oxygen-enriched atmospheres (areas) –precautions must be taken in oxygen-enriched atmospheres. Oxygen-enriched atmospheres include areas in which an oxygen delivery device has been connected to a flowmeter and the flowmeter is in the “on” mode, i.e. resident receiving oxygen via nasal canula, oxygen mask or other delivery device. According to the NFPA-99, once a device is connected to the flowmeter, the measures listed (below) would need to be followed:
- 6.1.1 Elimination of Sources of Ignition. It is very important that visitors be informed of a center’s policies so as not to jeopardize the safety of patients, other visitors, and staff through prominent posting of signs.
- 18.104.22.168 Smoking materials (matches, cigarettes, lighters, lighter fluid, tobacco in any form) all be removed from patients receiving respiratory therapy and from the area of administration. A policy on smoking should be developed for the entire center to avoid confusion and to generally reduce the hazard from smoking.
- 22.214.171.124 No sources of open flame, including candles, shall be permitted in the area of administration.
- 126.96.36.199 In health care facilities where smoking is not prohibited, precautionary signs readable for a distance of 5 feet shall be conspicuously displayed wherever supplemental oxygen is in use and in aisles and walkways leading to that area; they shall be attached to the adjacent doorways or to building walls or supported by other equipment.
- 188.8.131.52 In health care facilities where smoking is prohibited, and signs are prominently (strategically) placed in all major entrances, secondary signs with NO Smoking language shall be required.
- NFPA-99 Chapter 3, Definitions section 3.3.13 defines area of administration (as noted above) as: “Any point within a room within 15 ft (4.3m) of oxygen equipment or an enclosure containing or intended to contain an oxygen-enriched atmosphere.”
Therefore, according to NFPA-99 guidelines, smoking materials and any other source of ignition should be kept at least 15 ft. (4.3 m) away from an oxygen-enriched atmosphere such as a resident receiving oxygen via nasal canula, oxygen mask or other delivery device.
Providing a safe and healthy environment for residents, visitors and employees is the goal of every provider, and using the regulatory guidance to develop the smoking policies will ensure success of that goal.