Berwick Hospital Center

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 38776 Based on review of facility documents, observations, and staff interview (EMP), it was determined the facility failed to provide adequate climate control and Heating,Ventilation, and Air Conditioning (HVAC) in the inpatient behavioral health unit for one of one observation made (A0726). The failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. On June 24, 2025, the survey team toured the behavioral health unit and conducted staff interviews regarding the immediate action to place two fans at the nurses’ station pointed to the hallways to circulate air in the behavioral health unit. Staff knew a staff member was to be positioned at the nurses’ station at all times with the nurses’ station gate closed to maintain a barrier for patient safety. Staff were also educated on documenting the unit temperature and humidity every hour. Staff were interviewed regarding a new service contract established between the facility and [Name of Commercial HVAC Company]. The survey team observed a technician from [Name of Commercial HVAC Company] was onsite on June 24, 2025, to fix the broken chiller. On June 25, 2025, the survey team toured the behavioral health unit and conducted staff interviews regarding the fans in the nurses’ station. Staff were interviewed regarding the repairs made to the broken chiller. [Name of Commercial HVAC Company] was onsite to discuss a rental chiller with facility. There was documentation unit temperature and humidity were documented every hour. The temperature was 78.8 degrees F, and the humidity was 61.6%. The fans were running in the nurses’ station and medication room. On June 26, 2025, the survey team toured the behavioral health unit and conducted interviews with staff. Fans were operating in the nurses’ station and medication room. A staff member was present at the nurses’ station. There was documentation the unit temperature and humidity were documented every hour. The temperature was 78.2 degrees F and 54.7% humidity. Staff were interviewed regarding the rental chiller for the HVAC. The rental chiller was rented. There was documentation of proof of purchase and was scheduled to be delivered June 27, 2025. On June 27, 2025, the survey team toured the behavioral health unit and conducted interviews with staff. There was documentation the unit’s temperature and humidity were documented every hour. The temperature on the unit was 74 degrees F and 45% humidity. There was documentation the existing chiller was repaired on the evening of June 26, 2025, and the rental chiller was delivered June 27, 2025. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed on June 27, 2025. Cross reference 482.41(d)(4) Ventilation, Light, Temperature Controls”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 38776 Based on review of facility documents, observations, and staff interview (EMP), it was determined the facility failed to provide adequate climate control and Heating, Ventilation and Air Conditioning (HVAC) in the inpatient behavioral health unit for one of one observation made (A0726). Findings: Review on June 26, 2025, of the facility policy, “ Patient Rights Policy, “ no date of last review, revealed “ ... IV. Procedure 1. Upon admission to the Behavioral Health service, the patient and/or or patients authorized agent should be informed of the rights of the patient. 2. The Patient Rights document is given to the patient and/or authorized agent to read or should be read to the patient and a copy given to him/her in a language the patient can understand. ... “ Review on June 26, 2025, of the facility document, “ Berwick Behavioral Health Condensed Handbook For Patients, “ no date of last review, revealed “ ...Manual Of Rights ... Article IV: Right To A Humane Physical And Psychological Environment Statement of Principle. Every patient has the right to reside and be treated in a setting which preserves and promotes his physical and psychological dignity. ... “ Review on June 27, 2025, of the facility policy, “ Storage- Temp Control of Medications Policy, “ last reviewed June 2024 revealed “ ... 1.1 Drugs shall be stored properly, maintaining proper temperature in compliance with manufacturer specifications, to maintain potency and stability of the product. 2. Procedure: 2.1 Definitions Of Storage Temperature 2.1.1 Storage temperatures are defined as follows: ... 2.1.1.4 Room Temperature: A temperature held between 20 and 24 degrees C [Celsius] (68 and 75 degrees F [Fahrenheit]). ... “ An observation tour of the inpatient behavioral health unit was completed on June 24, 2025, at approximately 1300. The unit was hot; the air was thick and humid. The temperature and humidity in the hallway and patient rooms was 80 degrees F and 63% humidity. The temperature and humidity of the medication room was 83 degrees F and 62% humidity. There were two fans running in the medication room at the time of the observations. There were no fans in any other location within the inpatient unit. The patients were observed flushed and perspiring. Three patients were observed walking to the nurses ’ station and complained of the heat on the inpatient unit. Interview on June 24, 2025, with EMP3, at approximately 1315 revealed the facility chiller began to malfunction on June 21, 2025. EMP3 maintenance staff worked to repair the chiller but the chiller stopped working on June 22, 2025. EMP3 confirmed the facility was without HVAC from June 22, 2025. EMP3 revealed three maintenance staff had been working around the clock to repair the chiller with little success. EMP3 revealed the facility lost it ’ s HVAC contract with a commercial company when the previous owner had claimed bankruptcy approximately three years ago. EMP3 revealed they had called a commercial HVAC company for assistance, but the company would not come onsite without an active contract and proof of payment. EMP3 revealed since the conclusion of the contract with the commercial HVAC company the facility maintenance staff had completed routine maintenance and repairs to the facility ’ s HVAC. A request was made for the facility policy regarding facility HVAC and facility temperatures and humidifies on June 24, 2025. None was provided. The high temperature for Berwick, PA, the location of the BHU (Behavioral Health Unit), on June 24, 2025, was 93 F, on June 25, 2025, was 91 F, on June 26, 2025, was 82 F, on June 27, 2025, was 66 F. Interview on June 27, 2025, with EMP1, EMP2, and EMP3, at approximately 1200 confirmed the above findings. On June 27, 2025, the State Survey agency confirmed the issue related to inadequate climate control and HVAC was addressed.”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 19375 Based on documentation review and interview, it was determined the facility failed to develop an emergency preparedness program, affecting the entire facility. Findings include: 1. Review of documentation on January 23, 2025, at 12:00 p.m., revealed the facility failed to establish and maintain a comprehensive emergency preparedness program in accordance with 42 CFR 482.15 condition of participation to include the following standards: (a) Emergency Plan (b) Policies and Procedures (c) Communication Plan (d) Training and Testing Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the facility failed to establish an emergency preparedness plan, required to be in-place by November 15, 2017.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain means of egress requirements in three locations, affecting one of one floor. Findings include: 1. Observation on January 23, 2025, between 10:54 a.m., and 11:30 a.m., revealed the following exit locations, between exit discharge and “common way,” were not cleared of snow: a. 10:54 a.m., M Wing, b. 11:16 a.m., E Wing. c. 11:30 a.m., Psychiatric Unit. Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the means of egress deficiencies.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure 2012 New Hazardous areas are protected in accordance with 18.3.2.1. The areas shall be enclosed with a 1-hour fire-rated barrier, with a 3/4-hour fire-rated door without windows (in accordance with 8.7.1.1). Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and 8.4. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 and less than 100 square feet) g. Combustible Storage Rooms/Spaces (over 100 square feet) h. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in two instances, affecting one of one floor. Findings include: 1. Observation on January 23, 2025, between 10:22 a.m., and 11:11 a.m., revealed the following: a. 10:22 a.m., the former office, located within the Building Services area, is presently used as a storage room. The storage room door lacked a self-closing device. b. 11:11 a.m., the M Wing mechanical room door required adjustment to fully latch within the corresponding door frame assembly. Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the hazardous area enclosure deficiencies.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 19375 Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system six locations, affecting one of one floor. Findings include: 1. Observation on January 23, 2025, between 10:27 a.m., and 11:23 a.m., revealed the following areas lacked either ceiling tiles, or plaster ceiling assemblies: a. 10:27 a.m., Old Pharmacy area. b. 10:33 a.m., Kitchen Storeroom. c. 10:44 a.m., Electrical Room. d. 10:55 a.m., IT Room. e. 11:08 a.m., old Doctor’s Lounge. f. 11:23 a.m., M Wing Nurse’s Station. Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the automatic sprinkler system deficiencies.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 19375 Based on documentation review and interview, it was determined the facility failed to maintain heating, ventilation, and air conditioning, affecting one of one floor. Findings include: 1. Observation on January 23, 2025, at 11:45 a.m., revealed the facility lacked fire damper preventive maintenance data past 2016. Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the HVAC deficiency.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 18.7.1.4 through 18.7.1.7 This Standard is not met as evidenced by: 19375 Based on documentation review and interview, it was determined the facility failed to conduct fire drills in accordance with requirements, affecting one of one floors. Findings include: 1. Observation on January 23, 2025, at 11:50 a.m., revealed Psychiatric Hospital staff members have not taken part in fire drills since the facility opened in November of 2022. Note: only maintenance staff were listed as participants on fire drill documentation. In addition, the majority of fire drills conducted during the previous twelve month period were conducted in ancillary areas of the hospital, and not in, or around the Psychiatric Unit. Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the fire drill deficiencies.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 19375 Based on documentation review and interview, it was determined the facility failed to maintain the generator set in one instance, affecting one of one floor. Findings include: 1. Observation on January 23, 2025, at 11:55 a.m., revealed the facility lacked annual ninety-minute load bank testing data for the diesel generator set. Exit interview with the Facility Administrator and the Facilities Manager on January 23, 2025, between 12:10 p.m., and 12:20 p.m., confirmed the generator set deficiency.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the reason a patient refused to sign their Initial Treatment Plan on admission (MR7); the facility failed to ensure there was a documented reason a patient refused to sign their Weekly Treatment Plan (MR7 and MR9); and the facility failed to ensure a patients 30 day Treatment Plan review was completed 30-Day, 60-Day, 90-Day and 120-Day’s (MR7, MR8 and MR9). Findings include: Review on January 9, 2025, of the facility’s “Treatment Planning and Team Policy”, last revision date May 11, 2020, revealed “...IV. Procedure ...4. Multidisciplinary Team meetings ...Patient/representative involvement is reflected by the patient/representative signature on the plan ...” Review on January 9, 2025, of the facility’s “30 Day Summaries”, original effective date September 14, 2022, revealed “Purpose: The purpose of the 30 day review is to summarize a patient’s treatment course and continued treatment planning. Policy: It is the policy of the Behavioral health [sic] Services (BHS) for Older Adults patient summary will be completed every 30 days on all patients who are on the unit for 30 or more. Procedure: 1. Thirty day summaries will be completed on all BHS patients who are on the unit greater than 30 days. 2. The summary will be reviewed by the treatment team and discussed with the patient and / or his / her legal guardian. 3. If the 30 day falls on a weekend or holiday, the 30 day review will be completed on the business day before or after the 30,h [sic] day. 4. The thirty day summary will be completed in addition to weekly revisions of the Master Treatment Plan. “ Review on January 9, 2025, of the facility’s “BH Treatment Plan Update Form B” last revised May 2021, revealed a line for the date of review due at a minimum weekly. There are nine sections listing the following information: Updates to Problems/Goals As Identified In The Master Treatment Plan Initial Data Form; lined sections indicating the Problem number, Short Term Goals number, Progress Toward Short-term Goals: and blocks for the facility to check if Unchanged Resolved Revised. The tenth section lists New Problems identified and/or changes in medications or discharge date? With boxes to check Yes No (specify below). The eleventh section is identified as Justification for Continued Stay ...The twelfth section is Patient/Guardian Statement. I have reviewed Revisions and/or Additions to my treatment plan. I have asked questions of the staff and have received explanations regarding treatment. (If patient refuses to sign, or if clinically contraindicated please explain). There is a line for the Patient signature, Date, Time and Refused to sign, a line for Reason for refusal and a line for Guardian/DPOA signature, date and time. Review on January 9, 2025, of the facility’s “BHAddendumtoMasterTreatmentPlan [sic]” last reviewed May 2021, revealed lines for the Date, PatientName [sic], ResultsofRe-Examination [sic], Review/ResultsofTreatmentPlansfromadmissiontocurrent [sic] and ReasonsforContinuedStay [sic]. On the second page there are lines for TreatmentPlancurrentlyineffect,includingastatementthattheplanpresentstheleastrestrictive [sic] alternative consistent with adequate treatment for the condition: a line for Certificationthatthe currentTreatmentPlancanbeprovidedintheBehavioralHealthUnit [sic]. A line for The30 day treatmentplanhasbeenreviewedwithmeandIhavebeengiventheopportunitytoparticipate [sic] in planning my care during my hospitalization. A line for the Patient Signature, Date Time. A check box indicating DidnotSign [sic] Reasondidnotsign [sic] Guardian/DPOA signature, date and time. 1. Review of MR7 on January 9, 2025, revealed this patient was admitted to the facility on July 24, 2024, for evaluation and treatment of a mental health disorder. MR7 was discharged on October 23, 2024. Review on January 9, 2025, of MR7’s Initial Treatment Plan revealed the facility’s Treatment Team met on July 24, 2024. Documentation on MR7’s Initial Treatment Plan revealed this patient refused to sign this form. There was no documentation indicating the reason MR7 refused to sign the Initial Treatment Plan form. Review of MR7 on January 9, 2025, revealed the facility held this patient’s Treatment Plan review on September 4, 2024. There was no documentation MR7 was provided an opportunity to review, ask questions and signed this Weekly Treatment Plan Form B. Review of MR7’s Weekly Treatment Plan Update Form B on January 9, 2025, revealed this patient refused to sign these weekly updated forms on the following dates: July 31, 2024. August 7, 2024. August 14 and 29, 2024. September 11 and 18, 2024. October 2, 16 and 9, 2024. There was no documentation indicating the reason MR7 refused to sign the Weekly Treatment Plan Update Form B. Review of MR7 on January 9, 2025, revealed the facility completed a 30-Day Treatment Plan Review of this patient on August 21, 2024, and a 60-Day Treatment Plan Review on September 21, 2024. Further review revealed this patient refused to participate in the 30-Day and 60-Day Treatment Plan Review. There was no documentation indicating the reason MR7 refused to participate in the 30-day Treatment Plan review or the 60-Day Treatment Plan Review. Interview with EMP1 on January 9, 2025, confirmed the above findings at the time of the medical record review. 2. Review of MR8 on January 9, 2025, revealed this patient was admitted to the facility on June 1, 2024, for evaluation and treatment of a mental health disorder. MR8 was discharged on October 28, 2024. Review of MR8’s 30-Day Treatment Plan Review on January 9, 2025, revealed the facility completed a 30-Day review of this patient on July 1, 2024. Further review revealed this patient refused to participate. There was no documentation indicating the reason MR8 refused to participate in this patient’s 30-day Treatment Plan review. Review of MR8 on January 9, 2025, revealed this patient’s 60-Day Treatment Plan review was to be completed on August 1, 2024; the 90-Day Treatment Plan review was to be completed on September 1, 2024, and the 120-Day Treatment Plan review was to be completed on October 1, 2024. There was no documentation in MR8 indicating this patient’s 60-Day, 90-Day and 120-Day Treatment Plan reviews were completed. Interview with EMP1 on January 9, 2025, confirmed the above findings at the time of the medical record review. 3. Review of MR9 on January 9, 2025, revealed this patient was admitted to the facility on August 8, 2024, for evaluation and treatment of a mental health disorder. MR9 was discharged November 15, 2024. Review of MR9’s Weekly Treatment Plan Update Form B on January 9, 2025, revealed this patient refused to sign these weekly updated forms on the following dates: August 19 and 28, 2024. September 3, 16, 23 and 30, 2024. October 7, 21 and 28, 2024. November 11, 2024. Review of MR9 on January 9, 2025, revealed this patient’s 30-Day Treatment Plan Review was to be completed on September 8, 2024; the 60-Day Treatment Plan Review was to be completed on October 8, 2024, the 90-Day Treatment Plan Review was to be completed on November 8, 2024. There was no documentation in MR9 indicating this patient’s 30-Day, 60-Day and 90-Day Treatment Plan reviews were completed. Interview with EMP1 on January 9, 2025, confirmed the above findings at the time of the medical record review.”