Failure to Maintain Smoking Safety Standards and Updated Policy
Penalty
Summary
The facility failed to comply with NFPA 101 smoking regulations as evidenced by several deficiencies identified during document review, observation, and interviews. The facility did not have an updated smoking policy available for staff, as confirmed by both the Director of Nursing and the Director of Maintenance. Additionally, observations revealed discarded cigarette butts on the ground in multiple locations, including the back area by the dumpster and the rear parking area designated as a smoking area. Further inspection of the designated smoking area showed the absence of required safety equipment, specifically a noncombustible ashtray and a self-closing metal container for ash disposal. These deficiencies were confirmed by facility leadership during the exit conference. No information was provided regarding specific patients or their medical conditions in relation to these deficiencies.
Plan Of Correction
1. The facility has a Smoking Policy that is available for review. Kadima at Lititz is a no smoking campus. All ashtrays have been removed from around the facility. 2. The Smoking Policy will be placed in the Safety and Disaster Policy & Procedure Manual. 3. All staff will be educated on the smoking policy. 4. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.