Wireless Call Systems

Wireless Call Systems:  Federal Standards vs. State Standards 

Subject: F 252 and F 463 as they relate to the design of call systems in long term care facilities. 

CMS released a series of changes to the Federal Survey Guidelines, effective last month (June 12, 2009).   These new changes, as a group, are referred to as “the home like environment” survey guidelines. 

One area of resident care that is specifically addressed in these new guidelines is related to the institutional image that is imparted to residents and visitors of Skilled Nursing Facilities where lights and buzzers, typically associated with HOSPITAL emergency call systems, are frequently “alarming” and creating unnecessary noise, distraction and disruption in the Skilled Nursing environment.  The new guidelines highlight the fact that alarm bells and lights associated with the traditional call system are not only potentially harmful to residents, but unnecessary because of alternative technology that is available.  “Hospital style” call systems are the antithesis of what you would find in a normal, home-like environment. 

History: 
While other states still use hospital type emergency call systems in Skilled Nursing Facilities, most states recognize wireless, silent call systems as an approved alternative.  In California, the same wireless option is not currently available to Skilled Nursing Facility operators. OSHPD regulations have “institutionalized” the use of lights and buzzers in the Skilled Nursing environment by mandating that the same standard be used for emergency call systems IN BOTH Hospitals and Skilled Nursing Facilities.  The regulatory standard used by OSHPD for call systems is the recently revised version of UL 1069 (effective 11/1/2008).   

We believe that you will find that the CMS survey guidelines cited in this article DIRECTLY conflict with California’s OSHPD specifications and requirements for call systems.  The OSHPD specifications favor hardwired call systems (a more expensive option) and mandate lights and audible alarms.   

Two wireless call system manufacturers achieved UL 1069 certification in 2006 under the pre- 11/1/2008 criteria.  New installations of these previously approved SILENT, WIRELESS call systems were terminated by OSHPD on 11/1/2008, when the modifications to the UL 1069 standard went into effect.  Existing silent, wireless call system installations, completed prior to 11/1/2008, are still in place and have been “grandfathered in” by OSHPD. 

Please see the guidelines below.  These guidelines have been copied directly from the CMS notice.  After reading the guidelines please review our commentary located near the end of this document:  We encourage you to respond with comments of your own. 

F252 
(Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09) 

§483.15(h)(1) - A safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; 

Interpretive Guidelines: §483.15(h)(1) 
For purposes of this requirement, “environment” refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents’ rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A determination of “homelike” should include the resident’s opinion of the living environment. 

A “homelike environment” is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A personalized, homelike environment recognizes the individuality and autonomy of the resident, provides an opportunity for self-expression, and encourages links with the past and family members. The intent of the word “homelike” in this regulation is that the nursing home should provide an environment as close to that of the environment of a private home as possible. This concept of creating a home setting includes the elimination of institutional odors, and practices to the extent possible. Some good practices that serve to decrease the institutional character of the environment include the elimination of: 

A number of other products are also listed in this section.  We have copied the portion only relating to Call Systems to conserve space.  We will cover the other products in future articles. 

The widespread and long-term use of audible (to the resident) chair and bed alarms, instead of their limited use for selected residents for diagnostic purposes or according to their care planned needs. These devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic. For more information about the detriments of alarms in terms of their effects on residents and alternatives to the widespread use of alarms, see the 2007 CMS satellite broadcast training, “From Institutionalized to Individualized Care,” Part 1, available through the National Technical Information Service and other sources such as the Pioneer Network; 

F463 (Rev. 48; Issued: 06-12-09; Effective/Implementation Date: 06-12-09) 
§483.70(f) Resident Call System 
The nurses’ station must be equipped to receive resident calls through a communication system from-- 
(1) Resident rooms; and 
(2) Toilet and bathing facilities. 

Intent: §483.70(f) 
The intent of this requirement is that residents, when in their rooms and toilet and bathing areas, have a means of directly contacting caregivers. In the case of an existing centralized nursing station, this communication may be through audible or visual signals and may include “wireless systems.” In those cases in which a facility has moved to decentralized nurse/care team work areas, the intent may be met through other electronic systems that provide direct communication from the resident to the caregivers. 

Interpretive Guidelines: §483.70(f) 
This requirement is met only if all portions of the system are functioning (e.g., system is not turned off at the nurses’ station, the volume too low to be heard, the light above a room or rooms is not working), and calls are being answered. For wireless systems, compliance is met only if staff who answer resident calls, have functioning devices in their possession, and are answering resident calls. 

HealthCare Source’s opinion: 
We feel there are a number of problems with the OSHPD mandated call system standard, not the least of which is that the revisions to the UL 1069 standard occurred as a result the hard wire call system industry’s open and aggressive lobbying campaign.  The lobbying effort began after wireless call systems were finally able to attain UL 1069 approval under the prior standard.  But setting the issues of cost and special interest lobbying aside, we feel that there is more than enough CLINICAL conflict to justify a change in the OSHPD standard. 

Those of you who know us well are familiar with the fact that we have argued since June 2005 that OSHPD approved audible, lighted call systems are in conflict with Federal Survey Guidelines F 315 and F 316.  Those guidelines address resident incontinence.  It is our contention that the lighted, audible call systems used at night undermine the bowel and bladder training provided by Skilled Nursing daytime staff. 

At the introduction of the revised F 315 and F 316 Survey Guidelines in June 2005, an attached pre-amble said, “90% of all residents entering SNF facilities become incontinent within 90 days”.  The guideline actually states that more than 50% of all Skilled Nursing residents have incontinence issues.    Whichever statistic you use, how much could it be worth, socially and financially, if we reduce that number by even a small percentage? 

California has a long tradition of being a leader in the area of regulatory safety, and when the California regulations exceed the Federal standards, I generally support the stricter California standard as being the better alternative.  Examples of current ground breaking positive regulations are the CA TB 133 flammability standard and the new California Air Resources Board ATCM toxic emissions standard.   

But we feel that when a regulation’s values conflict with and/or undermines quality of care and quality of life values, then the conflicting regulation should be rescinded or modified 

It is our contention that OSHPD mandating the new UL 1069 standard for call systems in Skilled Nursing Facilities conflicts with the Federal Survey Guidelines F 252, F 463, F 315 and F 316.  That is, in our opinion, enough reason for the Skilled Nursing industry to take action and challenge the OSHPD call system standard. 

We can only hope that OSHPD will respond quickly and re-institute Skilled Nursing approval for those SILENT, WIRELESS call systems that met by the old UL 1069 standard.  That could be a fast, safe and simple solution to this problem.

CARB Regulations

§ 93120. Airborne Toxic Control Measure to Reduce Formaldehyde Emissions from Composite Wood Products. 

Notes on CARB Compliance issues specifically for the Health Care Industry. 

• HealthCare Source has received many inquiries from manufacturers, specifiers and end users regarding the California Air Resources Board (CARB) requirements for the Airborne Toxic Control Measure (ATCM) compliance of wood products and furniture used in health care facilities.  We thought posting a document addressing some of these questions and providing links to the regulators might prove helpful to our clients. 
• These new CARB standards apply to all hardwood plywood, particleboard and medium density fiberboard components used in ANY and ALL new finished products sold in California.  This means the CARB ATCM standard applies to all new furniture and wood finishing products (i.e.: Crown Molding) which we typically see used in health care facilities.   
• Should you care to read and interpret for yourself the information regarding this regulatory change, you can link directly to the California Air Resources Board at: http://www.arb.ca.gov/toxics/compwood/compwood.htm 
• You can read the chapter and verse of the CARB ATCM regulations at the following site: http://www.arb.ca.gov/regact/2007/compwood07/fro-final.pdf 

What does HealthCare Source think this regulation means to the health care industry??? 

• Starting with the raw material suppliers, everyone in the production and distribution cycle of wood based products must keep “chain of custody” records.  In the case of imported products, the importer is liable for owning and maintaining the chain of custody database.  Everyone who participates in the sale of non compliant wood based products in California is deemed liable to the regulation until they are individually cleared of culpability by CARB.  The violations are adjudicated by CARB on a case by case basis. The investigation of a violation could include any dealers, buyers and specifiers, along with the manufacturers, importers and distributors of non-compliant products. 
• Some of the wood furniture and products sold in California are manufactured in Europe and are advertised as being built to the E1 emissions standard.  This standard is very close to the Phase 1 version of the CARB ATCM standard.  Those manufacturers producing products that meet the E1 standard will more easily adapt to the new CARB regulations, but E1 certification does not automatically mean that those products have also attained CARB compliance.  They must additionally certify that the composite wood components used in the production of their product meet the CARB standards in order to be approved for sale in California.  
• California is often a leader in establishing regulatory safety standards and the CARB ATCM standard appears to be no different.  Minnesota and Oregon are already considering adopting this standard for their region, and the U.S. EPA recently sent out a Federal Register notice regarding their intent to create a Federal standard for composite wood and composite wood products.  We expect that the EPA will adopt a standard similar to the California standard for the entire nation. 

Notes to the health care industry: 

• We have all heard enough stories about lead paint on toys, melamine in milk and recalls of peanut butter to know that we should be vigilant about the products we buy and where we use them.  This caveat applies with a greater urgency to health care providers because of the vulnerability of those for which they care. 
•  And while we might teasingly think of CARB enforcement in the same context as “the mattress police”, the emissions from unregulated furniture have actually been tested as being very toxic.  Therefore, we don’t believe that it will be “the mattress police” who enforce this guideline on the health care industry.  Enforcement will come from the State, but it will also come from attorneys looking for another route in a liability action. This possibility renders CARB awareness for the health care industry as being a RISK MANAGEMENT issue. 
• Health care operators should also know that there is a window in which existing, non compliant furnishings can still be sold FROM INVENTORY by stocking DEALERS.  The fact that this window exists does not preclude the health care operator from the associated RISK of exposing the patient/resident/client to the toxic emissions of the “grandfathered” furniture. 
• Expect that Dealers and Distributors WILL BE DUMPING (very attractive pricing) non-compliant inventory, trying to get rid of it prior to the final disposal deadline (the RETAIL deadlines have recently been extended due to the economy. Refer to the CARB website link above for the most current deadline dates). All new products sold to health care facilities on or after January 1, 2009 and any new products built or imported beginning January 1, 2009 must be CARB compliant. 
• BE AWARE that as of the date of the publication of this article, non compliant RETAIL “ON-HAND  INVENTORY” stored in California can be sold in California through July 2010.  Health care providers who are significant consumers of these types of products should take the time to create a policy addressing how they plan to comply with the CARB ATCM standard and how they will avoid purchasing non-compliant products. 

What might you do to protect yourself? 

1. Insist that any furniture you buy be CARB compliant and demand that it be indicated as such on the label. 
2. Only buy furniture “factory direct” until the implementation period is over (currently July 2010).  Do NOT buy from stock inventories unless you KNOW the furniture is compliant. 
3. Do not purchase ANY retail furniture for your facility.  Especially retail seating which probably is also not CA TB 133 flammability compliant. 
4. Refer back to your recent furniture purchases starting from January 1, 2009 to present. If they do not have CARB compliant labels, demand the chain of custody information from the manufacturer/importer/dealer so you can defend any litigation.

How do you know your furniture is CARB ATCM compliant?

Now that CARB ATCM Phase 1 is in full effect, people ask us, "how do we know if the furniture we bought is CARB compliant?". 

All institutional furniture sold to California end users after April 1, 2009 was required to be CARB ATCM compliant.

1. Check your copy of your invoice for written certification of CARB ATCM compliance on the invoice.   
2. Check the label on the product for written certification of CARB ATCM compliance. 

If you cannot find evidence of CARB ATCM compliance on either the document or the product, it will be assumed that the product is NOT CARB compliant. 





Beginning April 1, 2009 the manufacturer of furniture sold to California end users was required to take the following actions and maintain the following records: 

1. ALL composites used in the manufacturing of the product must comply with the emission and certficiation requirements of the rule. 
2. The manufacturer must keep all records of composite material purchases for at least two years. 
3. A label is required for every product OR box that the product is shipped in. This label may be applied as a stamp, tag, sticker or bar code. 
4. The label must include the manufacturer's name, the production date and the compliance standard for composite(s) that were used in the production of the product.  
5. Additionally, providing the end user with written documentation of compliance by the composite supplier(s) is highly recommended. 

If you purchased your furniture from a dealer, Beginning April 1, 2009 Dealers were required to take the following actions and maintain the following records. 

1. The dealer must maintain purchasing records for composites and/or fabricated products containing composites for at least two years.   
2. The dealer must receive written documentation of product compliance from the manufacturer.  Providing the documentation to the customer at point of sale is highly recommended. 

So, what do I do if I can't find my evidence of CARB ATCM compliance? 

• CARB ATCM is a "chain of custody" regulation.  If you purchased your furniture from a dealer, the dealer is required to provide you evidence of certification for at least two years should you request it. 
• If you purchased your furniture from the factory, the factory is required to provide you with evidence of certification for at least two years should you request it. 

So, what if the dealer or the factory cannot provide the required evidence of certification as required by the CARB ATCM regulation? 
You have two issues to address: 

1. Replacing your product/furniture with compliant product and/or 
2. Filing a complaint with CARB enforcement to see if they can get the required documentation for you. 

Phase 2 of the CARB ATCM standard began 1/1/2010.  Be certain that your product is at the current level of compliance.