INITIAL COMMENTS
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This report is a result of an onsite complaint investigation conducted on April 9, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the complaint investigation, Conewago Synder, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.8 (1) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on the physical plant inspection, staff and patient interviews, and a review of facility grievances, the facility failed to have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
It was reported by facility staff and patients that there have been ongoing issues with the first floor Heating Ventilation and Air Conditioning (HVAC) systems. The malfunctioning HVAC system has resulted in extremely cold temperatures or extremely hot temperatures.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
On 5/5/25 and 5/6/25, the HVAC system on the first floor was serviced and repaired to restore proper heating and cooling function. The system is now operating within the required temperature range.
To ensure ongoing compliance and prompt response to future HVAC concerns, monitor staff will check and record thermostat readings during each shift's off-hours rounds. Any heating or cooling issues will be documented in the facility communication log, which is maintained within the EMR. The Director of Maintenance will review the communication log daily and respond to reported issues promptly. All staff have been instructed that they may report HVAC concerns directly in the communication log to ensure centralized reporting and timely resolution. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection that took place on April 9, 2025, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. A portable space heater was observed in the first floor closet.
This finding was reviewed with the facility staff during the complaint investigation.
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Plan of Correction
On 4/9/25, the Facility Director instructed the Facility Maintenance Director to remove all portable space heaters from the property. On 4/10/25, the Facility Director and Facility Maintenance Director conducted a walkthrough of the facility to confirm their removal. On 4/23/25, during the facility staff meeting, all staff were reminded that portable space heaters are not permitted in the building.
To ensure ongoing compliance, the Facility Maintenance Director will check for unauthorized space heaters as part of the weekly fire safety and sanitation inspections conducted every Friday via a whole facility walkthrough. The inspection form is maintained within the facility's EMR for documentation and compliance tracking. Any space heaters discovered will be removed immediately, and staff found in violation will be addressed in accordance with facility policy.
The Facility Director will review and sign off on each weekly inspection in the EMR prior to the next scheduled inspection and will follow up on any noted violations. In addition, reminders regarding the prohibition of space heaters will be provided regularly during monthly staff meetings to reinforce staff awareness and accountability.
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