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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

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.