Noncompliance with Smoking Policy by Facility Staff
Penalty
Summary
Facility staff failed to adhere to established smoking regulations as required by 19.7.4. During an observation, two employees were seen smoking outside on the campus grounds at a picnic table near the building, which was not in accordance with the facility's smoking policy that only permits smoking inside personal vehicles. This noncompliance was confirmed through a review of the facility's smoking policy and an interview with the Maintenance Director at the time of the observation. The deficiency was identified as potentially affecting 26 occupants in the event of a fire, as the required smoking regulations were not fully implemented or enforced.
Plan Of Correction
Element #1 The facility smoking policy was reviewed and acknowledges the facility will not provide a designated outdoor smoking area on facility property. Staff are permitted to smoke in their vehicle. Element #2 All staff will be re-educated on the smoke free facility policy and procedures by 5/26/25 or prior to their next day worked in the case of the leave of absence or vacationing employee. Element #3 The EVS manager and/or designee will audit four to six times weekly to validate staff adherence to the smoke free facility policy and smoking only off premises or in their personal vehicles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee Monthly times one, and periodically thereafter. The Administrator will assume responsibility for attained compliance.