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.