Non-Compliance with Smoking Regulations
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations due to several deficiencies. During a document review, it was discovered that the facility did not have a documented smoking policy available for review. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. Additionally, the facility failed to post no smoking signs in areas where flammable liquids, combustible gases, or oxygen are used or stored, which was also confirmed during the exit conference interview. Furthermore, observations revealed that the facility did not provide metal containers with self-closing cover devices for ashtrays, nor did it have fire-resistant ashtrays in the designated smoking area behind the facility at the picnic table. This area was found to have an abundance of cigarette butts discarded on the ground, indicating a lack of proper receptacles. The absence of these required receptacles was confirmed during the exit conference interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1 and 2. Maintenance Director will print smoking policy for life safety binder, will post non-smoking signs in rooms, wards, or compartments where flammable liquids, combustible gases or oxygen is used or stored and will provide metal receptacles to be available where smoking is permitted. 3. Maintenance department will be educated on the standards of the facilities smoking policy, need for non-smoking signs, and providing metal receptacles where smoking is permitted. 4. Maintenance or facility designee will audit facilities smoking policy, metal receptacles, and non-smoking signs to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.