Best Practices Related To Smoking In Long Term Care Settings And .

Best Practices Related to Smoking in Long Term Care Settings and Resident Rights Mary McKenna, Director State Long Term Care Ombudsman Program Executive Office of Elder Affairs Sherman Lohnes, JD, Director Division of Health Care Facility Licensure and Certification Department of Public Health Beth Scheffler, MSN, APRN, Complaint Unit Manager Department of Public Health Introduction True or False: 1. Smoking is a privilege that long term care facilities can restrict when necessary, so long as they have a written policy and procedure outlining rules for smoking that the resident has signed in advance. 2. A resident who is on oxygen and who is their own decision makers may smoke with their oxygen present, so long as it has been turned off, they do so outside, and the facility has advised the resident of the risk. 3. There is no real benefit in quitting smoking for elderly nursing homes residents who have smoked all their life. Slide 2 1

State Law Restricting Smoking 1987: MGL Chapter 111, section 72: Nursing home common areas must have designated no smoking sections Employees prohibited from smoking in resident care areas 2004: MGL Chapter 270, section 22: All workplaces must be smoke free Nursing home not considered a “residence” for smoking purposes Nursing homes may apply to the local board of health to designate part of facility as a “residence” – – – – Entire facility may not be designated as a residence Designated area must be for “sole use of permanent residents ” Temporary or short term stay residents may not reside in designated area Nursing home must make reasonable accommodation for employees, residents, and visitors who do not wish to be exposed to tobacco smoke – All remaining areas must comply with smoke free requirements Slide 3 Law & Regulation Impacting Smoking Massachusetts General Laws Chapter 111, section 70E Every patient or resident of a facility shall have the right (c) to have all reasonable requests responded to promptly and adequately within the capacity of the facility State Regulations: 105 CMR 150.015(D)(9): No residents shall be permitted to have access to lighter fluid or wooden household matches. Federal Regulations (under F571): (ii) Items and services that may be charged to residents’ funds (C) Personal comfort items, including smoking materials, notions and novelties, and confections. Slide 4 2

Approach to Smoking in the Nursing Home There is no question about the health hazards associated with smoking. Nursing home residents, like adults in the community, can choose to smoke. This can and does cause conflicts within a nursing home. Instead of “we can’t do that,” try asking “how can we make it work?” Slide 5 It is their Home Facilities must balance supervision and safety of all residents, including those who smoke. Given that this is a resident’s home, facilities must take into account their needs as well as their preferences and choices. For some, smoking is a choice. What does not work is a “cookie cutter” approach. Slide 6 3

Person-Centered Care A nursing home must ensure that it provides person-centered care to residents in a manner that allows them to exercise their rights to the extent that is possible. According to the Centers for Medicare and Medicaid Services (CMS), person-centered care focuses on the resident as the locus of control and supports the resident in making their own choices and having control over their daily lives. 483.10 (b) Exercise of Rights: The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Slide 7 483.10: Resident Rights: Part of the Federal Requirements, designed to ensure quality individualized care Respect and dignity Exercise rights without fear Reasonable accommodation Assessment Care Planning Slide 8 4

F926: Establish Policies The Facility must develop policies in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. Slide 9 How to make it work for the residents and you? Individualized assessment; again, not a blanket approach. Listen to the resident, include them in the care planning, and present ideas with a positive approach. Involve the resident in planning and design of the policy: spell out parameters/limits and use a team approach so that residents and staff determine a policy that works together. Slide 10 5

Best Practices Present changes in small steps, through dialog versus all at once. Involve staff in policy design too. They often know best what is needed to make a process work. Use the Facility’s Assessment to determine training and staffing needs of residents and staff. Slide 11 What makes a good policy? Based on Facility Assessment Individualized Resident Assessment Resident involvement in design Reflect understanding of state and federal laws and safety standards Flexibility Is modified as needed to meet resident and facility needs Slide 12 6

Admission Policies F620: The facility must establish admission policies: Cannot have Residents waive their rights as a condition of admission. §483.15(a)(6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility. Slide 13 Regulatory Framework: Rights & Safety Areas to Consider: Risks/Safety: Matches/Lighters Lighter Fluids and Wood Matches – Prohibited under State Law Behavioral Issues or Challenges Impact to Non-Smokers Adaptive Equipment Rights: Self-Determination Reasonable Accommodations Property – Secured Visitors – bringing in items Refusal of Treatment To Remain in Facility Potential Cites*: F622 – Reason for Discharge F623-F626 – Notice/Process Regarding Transfer or Discharge F557 – Personal Belongings F689 – Free of Hazards F926 – Establish Polices and Procedures in Accordance with law and regulations F558 - Accommodation of Needs F585 - Grievances *Note: This is not an all-inclusive list of potential cites. Slide 14 7

Accommodation of Needs Federal requirements at§483.10(e)(3): The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The environment must reflect the unique needs and preferences of each resident to the extent reasonable and does not endanger the health or safety of individuals or other residents. Massachusetts General Laws Chapter 111, section 70E: Every patient or resident of a facility shall have the right (c) to have all reasonable requests responded to promptly and adequately within the capacity of the facility Slide 15 F561: Self-determination The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. The right to choose activities, schedules (including sleeping and waking times), health care, and providers of health care services consistent with his or her interests, assessments, and plan of care. The right to make choices about aspects of his or her life in the facility that are significant to the resident. Slide 16 8

Regulatory Framework: Health Areas to Consider: Admission Potential Cites*: F620 Assessment Care Plan Implement Qualified Personnel Policies Medical Director Oversight Possession Smoking in an unsafe manner – oxygen, inside in non-designated approved areas Behaviors – sharing with others – Admission Policy F636 – Assessment F639 – Care Plan F658 – Standards of Care F659 – Plan of Care F684 – Care and Services F841 – Medical Director F926 – Policy Development *Note: This is not an all-inclusive list of potential cites. Other areas or additional cites may be triggered based on specific findings when appropriate. Slide 17 §483.25(d): Accidents The facility must ensure that: §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and, §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents Slide 18 9

F689: Smoking Assessments Residents must be assessed to determine whether they are safe to be independent Identify Resident capabilities and deficits – all to drive care plan interventions such as: – Need for assistance Managing materials Apron use Assistance to approved location Need for adaptive equipment – Need for Supervision – Education regarding smoking cessation strategies Slide 19 Assessment Considerations Indication of burns on residents or their clothing? Dexterity issues – adaptive equipment needed? Not properly extinguishing smoking materials? Not smoking in approved areas – Smoking near or around hazardous materials – oxygen or chemicals? – Sharing smoking materials Access to unsafe materials – lighter fluid and wood matches are prohibited, lighters, cigarettes, etc., will need to be secured This speaks to a need for re-evaluation of need for level of supervision and assistance needed to assist the resident to make their choice to smoke. Slide 20 10

Care Plan Education regarding activities which place a resident at risk should be provided. Given the serious adverse consequences of smoking, the resident should be provided on-going re-assessment and care planning related to smoking cessation strategies and education. This does not mean all decisions regarding unsafe behaviors can continue without further intervention or action. For example: Residents cannot choose to smoke in the presence of oxygen, regardless of whether they were educated on the risks of doing so. Slide 21 What Happens When a Resident’s Choice Does Not Match the Facility’s Expectations? Slide 22 11

Discharging Residents Office of Medicaid Board of Hearings Decisions have been rendered regarding attempts to discharge residents for not adhering to a facility’s smoking policy. The most recent cases were in 2018, and facilities lost the discharge requests for these cases. Slide 23 Tobacco Cessation The Massachusetts Tobacco Cessation and Prevention Program (MTCP) is a statewide public health program focused on comprehensive approaches to reduce tobacco and nicotine use. n-and-prevention-program-mtcp Slide 24 12

QUESTIONS? Slide 25 Resources Revised CMS “State Operations Manual” Appendix PP: ds/Surveyand-Cert-Letter-17-07.pdf Massachusetts Tobacco Cessation Program (MTCP): on-andprevention-program-mtcp Slide 26 13

State Law Restricting Smoking 1987: MGL Chapter 111, section 72: Nursing home common areas must have designated no smoking sections Employees prohibited from smoking in resident care areas 2004: MGL Chapter 270, section 22: All workplaces must be smoke free Nursing home not considered a "residence" for smoking purposes