This week’s “Ftag of the Week” on the CMSCG Blog is F926 Smoking Policies. This is part of the Physical Environment regulatory group. This regulation requires that nursing homes establish policies for smoking, tobacco cessation, smoking areas, and smoking safety (for both smokers and non-smokers) that are compliant with Federal, State and local laws and regulations.
The Interpretive Guidance for F926 is very brief and only states that the use of oxygen in smoking areas is prohibited, as is the use of oxygen while smoking. Surveyors are directed to the Guidance at F689 Free of Accident Hazards/Supervision/Devices related to smoking. Why not, when there is a section of F689 that specifically addresses resident smoking! While the F689 Accidents Ftag was traditionally used for smoking concerns, F926 was added in when the Requirements of Participation were updated. This means that a facility that allows smoking and where surveyors identify problematic practices could potentially be cited under both regulations. Surveyors are instructed to look for smoking not just by the residents, but staff, visitors and others who are on the facility grounds. Smoking areas both inside, if any, and outside the facility are to be observed by a member/s of the survey team. Additionally, surveyors will inquire of residents who smoke what the facility’s plan is that allows them to smoke.
As mentioned, F689 is often where Smoking issues are cited, however, F926 can also be cited, even at an Immediate Jeopardy level, as it was for one facility recently. At that facility, a resident who received continuous oxygen and had an oxygen tank on his wheelchair was smoking in bed and lit the resident’s bed and privacy curtain on fire. The facility’s policy did not address safety for residents who want to smoke but use oxygen. A Safe Smoking Program needs to address the procedure to follow to avoid such a negative outcome as well as outline overall safe smoking practices.
Allowing smoking, in general, in a nursing home requires the development of a Safe Smoking Program that is strictly followed to ensure the safety of everyone in the facility, not just those residents who smoke. A Safe Smoking Program means that there is an appropriate assessment of each resident who smokes with a focus on each resident’s ability to smoke safely, whether or not he/she can smoke independently, require supervision, need a protector for his/her clothing or adaptive equipment to hold a cigarette when smoking. Following this assessment, which should be completed on a periodic basis, education should be provided to the resident on the program, the facility’s expectation of compliance with the Safe Smoking Program, etc.
Many facilities require smokers to sign an agreement that indicates the resident will follow the safe smoking procedures in the facility, including if there are specific times for smoking, and that they understand that their smoking privileges may be revoked, even for a limited period of time, for non-compliance with smoking procedures.
I think we have all heard a story of a resident who self-ignited their clothing and died related to the injuries sustained in this kind of accident; this type of accident which unfortunately happens (even if it is a rarity) usually makes the headlines. Following one of these events, you have to think about how a facility addressed the storage of each resident’s smoking paraphernalia – did the resident maintain his/her own cigarettes, lighter or matches or did the facility have a plan for management of these items? Did the resident did not follow the safe smoking protocols or the did facility staff fail to carry out their responsibilities related to the Safe Smoking Program? Couple that with the questions – was the resident provided with appropriate supervision while smoking and did we following the resident’s plan of care related to safe smoking? Lastly, should part of your Safe Smoking Program include staff oversight during all smoking sessions?