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Long-Term Care Survey Alert

Resident Assessment:

Shore Up Supervision & Safety Practices for Residents Who Smoke

Published on Sat Jan 01, 2011

The BIMS isn't an accurate cognitive assessment for this purpose, expert warns.

"The really important take-away" from a November CMS survey memo on smoking safety "is that facilities are responsible for assessing each resident to determine whether they need to be supervised while smoking," says attorney David Bufford.

"That assessment has to be well documented and must look at the individual factors for that resident -- their cognitive ability and judgment, manual dexterity, and mobility," adds Bufford, with Hall, Render, Killian, Heath & Lyman in Louisville, Ky., who also wrote about the memo in his blog.

Solid bet: "Surveyors are going to be looking at the factors used in that assessment and how well the facility documented the assessment," predicts Bufford, warning that the survey memo "could put that in the forefront of surveyors' minds..."

"The facility also has to do a reassessment ... to identify any changes that might prevent the person from being an unsupervised smoker," Bufford tells Eli.

"The situation that culminated in CMS sending out the memo, based on how it reads, is ... a really tragic accident brought about by multiple failures of supervision," says Bufford. "The person wasn't wearing a smoking apron and wasn't being adequately supervised. A fire extinguisher was available, but was blocked by the person in the wheelchair who was smoking."

In the view of Diana Waugh, RN, BSN, the MDS 3.0 "Brief Interview of Mental Status (BIMS) does not provide sufficient information about the level of the resident's cognitive loss -- nor was it intended" to do so. Instead, facilities should consider using the Allen Cognitive Levels, an "assessment of cognitive functional age that has been taught in occupational therapy school for the last 25 years," advises Waugh, principal of Waugh Consulting in Waterville, Ohio. There's also the Reality Comprehension Clock Test (RCCT), "another CFA assessment that has been researched and validated looking at the exact population as found in long-term care facilities." Waugh says that she "can't imagine that if a resident's score on either CFA assessment supported that they process information at the age of a five-year-old, they would be allowed to smoke unsupervised, regardless of their social verbal skills."

"You should consider whether the person who can smoke without supervision at 9 in the morning can do so at 7 in the evening, if you're sending people out to a sheltered area where there are shadows and it's dark," advises Joy Jordan, MSN, RN, SMQT Certified, RAC-CT, a former surveyor who is currently clinical operations consultant with Boyer and Associates in Brookfield, Wis.

Jordan also advocates assessing whether staff should give the resident a cigarette and lighter -- "or maybe even light the cigarette for the person so that the staff is in control of the actual fire and lighter." In addition, "all residents should be wearing smoking aprons. Also look at what type of structure that the smokers are sitting on to make sure that it isn't flammable," Jordan adds.

Also: "Any smoking determination should be part of the resident's plan of care so that everyone on staff knows how to adequately deal with the resident," Bufford says.

"The plan should be individualized," Jordan emphasizes, and "identify the degree of safety and who gets their cigarette lit and who's safe in the morning but not at night, and so on."

Determine When to Reassess

The F323 guidance doesn't indicate how often facilities should reassess the resident, Bufford says. "I would not necessarily recommend a set timeframe as the person could develop cognitive or other problems rendering them unable to smoke unsupervised before the next assessment is due," he instructs. "Rather it should be based on monitoring the individual and modifying any interventions to address any changes in that individual's ability to smoke unsupervised," Bufford adds. "Obviously, however, the assessment should be included, at the minimum, in any regularly scheduled evaluations, such as an MDS or a significant change evaluation."

Bufford notes that the "only new item that CMS brought out in the memo is the use of electronic cigarettes. CMS says those are battery operated and heat a cartridge that atomizes a chemical. But the electronic cigarettes don't pose the same risk as actual cigarettes and are not considered to be a smoking device."

MDS 3.0 coding tip: The RAI User's Manual states that J1300: Current Tobacco Use "opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed."

Resource: You can access the survey & cert memo at https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_04.pdf.

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