Smoking Policy in Nursing Homes
PDF Version of
BQA 05-008 (PDF, 51 KB)
DATE: June 15, 2005 DSL-BQA-05-008
Supersedes 98-063
To: Nursing Homes, NH 005
From: Cris Ros-Dukler, Director, Bureau of Quality Assurance
The Bureau of Quality Assurance continues to receive questions
concerning smoking policies in federally certified and state-licensed
nursing homes. This memo will reiterate and amplify many of the issues
addressed in BQA memo 98-063. The major purpose in reissuing this memo is
to encourage facilities to:
(1) Develop comprehensive and explicit written policies and procedures
concerning smoking. The clearer and more explicit a facility's policy is,
the less likely that conflicts will arise later and, if conflicts arise,
the more likely they will be resolved easily.
(2) Balance the rights of residents with (a) the right of the facility to
prohibit smoking within the building and/or on facility grounds, and (b)
the necessity of protecting non-smokers from the dangers of second-hand
smoke.
General Bureau Philosophy:
While the Bureau of Quality Assurance recognizes the dangers of
smoking, we also recognize that some older individuals have smoked for
years and take pleasure in the act of smoking and related social
interactions. We are also cognizant of the fact that while the nursing
home is a place of employment for some, it is home for others. The guiding
principles in the development of this memo are:
- The Wisconsin Clean Indoor Air Act (section 101.123, Wis. Stats.),
which prohibits smoking in all inpatient health care facilities (which
includes nursing homes) unless the person in charge, or his or her
agent, designates smoking area(s) in the facility.
- The right of each facility to develop its own policies and
procedures for smoking in the facility and on the facility grounds.
These policies must comply with any overriding local ordinances
related to smoking.
- The responsibility of facilities to accommodate and meet the needs
of all residents. Facilities are responsible for finding "options
that most meet the physical and emotional needs of each resident"
(Guidance for 42 CFR 483.15 (g)(1)[F250]) and for accommodating
"an individual's needs and choices for how he/she spends time,
both inside and outside the facility." (Guidance for 42 CFR
483.15(d) [F245].
- Residents' rights to make choices about aspects of their lives in
the facility that are significant to them. CMS interprets this to mean
that residents are "grandfathered" under the smoking policy
in effect when they were admitted. Guidance for 42 CFR 483.15
(b)(3)[F242] says, "…if a facility changes its smoking policy
and prohibits smoking, it must allow current residents who smoke to
continue smoking in an area that maintains the quality of life for
these residents."
- The facility's responsibility to inform a resident, either before or
at the time of admission, of his or her rights and all rules and
regulations governing resident conduct. [42 CFR 483.10 (b)(1)].
Facility smoking policies: BQA encourages facilities to develop
written policies and procedures that clearly identify:
- whether smoking is allowed and where it is allowed;
- what accommodations for smoking are provided; and
- the type of staff assistance that will be given with smoking.
These policies and procedures should be clearly explained orally and in
writing to all new or prospective admissions. A facility policy that
clearly articulates smoking restrictions will allow potential residents to
determine if they can abide by the conditions of the policy when they are
considering admission. An explicit policy will also help deter or settle
issues that might arise concerning smoking.
As you develop your policies, please keep the following in mind: Some
individuals who are admitted to a facility that permits smoking may have
or develop serious physical, mental or cognitive disabilities. These
residents do not lose their right to smoke because they need monitoring
and assistance by facility staff for safety. A facility's smoking
policy, however, may provide reasonable limitations and restrictions on a
resident's right to receive staff assistance to smoke (time of day,
weather conditions, frequency, type of assistance that will or will not be
provided, including assistance with the actual act of smoking, etc). The
clearer the policy, the less likely that conflicts will arise later.
In all cases involving residents who are able to smoke safely and
without assistance, staff must help transport the residents to and from
the smoking area if the resident needs this type of assistance. This
includes transporting residents living in a secure unit to and from the
designated smoking area and monitoring their whereabouts once at the
designated smoking area. For residents who are not able to smoke
independently, facility policy may establish reasonable limitations and
restrictions concerning the amount and type of staff assistance that will
be given with smoking.
Surveyors will determine whether a facility is honoring the right of
residents to make choices about aspects of their lives in the facility
that are significant to them in regard to smoking by evaluating how
the facility's smoking policies are being implemented.
A number of scenarios are provided below to assist you in clarifying
your smoking policies, while fulfilling your mission of meeting the
physical and emotional needs of residents.
- Facility has no policy prohibiting smoking and there are no
city/county ordinances that prohibit it. The Wisconsin Clean
Indoor Air Act (section 101.123(4)(a)1, Wis. Stats.), permits smoking
in an inpatient health care facility only if the person in charge, or
his or her agent, designates smoking area(s) in the facility. Smoking
is not allowed within the nursing home if the person in charge or
his/her agent has not designated a smoking area.
- Facility policy allows smoking and there are no city/county
ordinances that prohibit it. Under the Wisconsin Clean Indoor Air
Act, the person in charge may not designate the entire facility as a
smoking area. Section 101.123(5), Wis. Stats., requires either the
person in charge or his or her agent to post signs identifying
designated smoking areas and to arrange seating to accommodate
nonsmokers.
Facilities need to assure that the rights
of all smoking and non-smoking residents are protected. Facilities
should be particularly conscious of the dangers of second-hand smoke,
and should strive to protect the rights and health of nonsmokers.
Physical plant characteristics should be taken into account when
designating a smoking area, including its proximity to rooms where
residents may be subject to second-hand smoke.
- Facility policy allows smoking in designated areas but a local
unit of government passes an ordinance or resolution prohibiting
smoking. If a local unit of government, such as the fire marshal
or city/county board, passes an ordinance or resolution prohibiting
smoking, the facility must change its policy beginning with the
effective date of the ordinance or resolution. When there is a change
in law or in facility policies governing resident conduct, federal and
state nursing home regulations require the facility to give oral and
written notice of the change to the resident or legal representative
in a language the resident or legal representative understands. (42
CFR 483.10(b)(1)[F156], HFS 132.31(1)(d)(intro.) and 1.h., Wisconsin
Administrative Code). The federal regulation also requires the nursing
homes to obtain written confirmation from each resident or legal
representative acknowledging his/her receipt of the notice of the
change.
Under this scenario, residents retain the
right to smoke outside the building. Conditions and requirements for
outdoor smoking are addressed later in this memo. Current residents
are not grandfathered in terms of smoking inside the building.
- Facility changes its policy and becomes a non-smoking facility or
campus. If a nursing home changes policy by either (a) prohibiting
all smoking within the building or (b) prohibiting smoking in the
building and on facility grounds, this must be clearly stated
in a revised admission agreement. The facility should notify the
community, potential visitors, referral sources, and current residents
of the change. Residents who are admitted on or after the effective
date of the policy are subject to the new restrictions.
The facility must make reasonable accommodations, however, for
residents who were admitted prior to the change. This is in keeping
with the resident's right to make choices about aspects of his or her
life that are significant to the resident. (42 CFR 483.15(b)(3)
[F154]). This applies to all such residents, including residents who
transfer from one unit to another, and those who live in a closed
unit, e.g., a locked, secured or supervised unit.
Designated outdoor smoking areas: If facility policy allows
residents to smoke outdoors, facilities should strive to protect the
rights and health of nonsmokers. A designated smoking area located outside
should be in an easily accessed area adjacent to the facility that is
protected from the weather (e.g., covered, wall or fence on one side if
there are winds typically from one direction, etc.). The area or areas
must protect nonsmokers from the potential hazards of second-hand smoke.
For any nursing home considering becoming a non-smoking facility or
campus, we reiterate the advice provided in BQC-91-007 (January 30, 1991).
While "we are all keenly aware of the dangers of smoking, we also
recognize that many residents have smoked for years…and depriving them
of the opportunity to smoke could be counterproductive to their welfare.
We encourage consideration of the residents' rights issues and
accommodations for those who wish to smoke, and strongly urge that before
implementing total smoking restriction in your facility, the psychological
and social impact upon your residents be carefully reviewed."
If you have additional questions, please contact the Regional Field
Operations Director assigned to your facility. The names and phone numbers
of the Regional Field Operations Directors are listed below:
Joanne Powell
Regional Field Operations Director
Northern (Rhinelander) Regional Office
(715) 365-2802
Joanne Powell
Acting Regional Field Operations Director
Northeastern (Green Bay) Regional Office
(920) 448-5249
Paul Peshek
Acting Regional Field Operations Director
Southeastern (Milwaukee) Regional Office
(414) 227-4908
Pat Virnig
Acting Regional Field Operations Director
Southern (Madison) Regional Office
(608) 243-2374
Joe Bronner
Regional Field Operations Director
Western (Eau Claire) Regional Office
(715) 836-4753
Last Revised: February 18, 2009 |
