CMS recently updated the Survey Resource folder, including revisions to several Critical Element Pathways (CEPs).
Most of the changes were typographical in nature. However, the Respiratory Care CEP (CMS-20081) included a clarification related to smoking signage requirements in areas where oxygen is stored or used. At first glance, this may appear to be a small detail. In practice, it is the type of issue surveyors are actively reviewing under the revised CEP.
We recently heard from a non-smoking facility that was informed during its annual survey exit that the absence of appropriate “No Smoking” signage at an employee entrance would be cited. Although the surveyors did not provide the specific F-tag or scope and severity level at exit, the discussion underscores how closely environmental safety details are being evaluated.
Previously, under Observations, the pathway asked surveyors:
“Are ‘No Smoking’ Signs present wherever oxygen is stored and/or administered?”
The revised CEP now distinguishes between smoking and non-smoking facilities.
The updated guidance states:
Smoking facilities:
Are doors labeled “No Smoking” at all locations where oxygen is stored or used?
Non-smoking facilities:
Are “No Smoking” signs posted at all major entrances and on doors to all oxygen storage locations?
This clarification does not create a new regulatory requirement. However, it refines how surveyors evaluate environmental safety compliance during respiratory care observations.
Environmental details such as signage and oxygen storage should be periodically reviewed to ensure alignment with current surveyor tools. Incorporating updated CEP guidance into mock surveys helps identify small but citable issue before they appear on a CMS-2567. If your organization would like to assess survey readiness, reach out to Polaris Group for individualized review and guidance.
