public-health-and-board-of-health-2019-2022-strategic-plan_comprehensive_final

              Town of Plymouth Public Health and Board of Health 2019 - 2022 Strategic Plan and Roadmap  May 22, 2019        Authored by the Town of Plymouth’s:  Department of Public Health  Board of Health   In Collaboration with Department of Planning  and Development    1        Town of Plymouth Board of Health and Department of Public Health Strategic Plan  Table of Contents  Plymouth Public Health at a Glance  4  Public Health 1.0 Yearly Activity and Future Priorities  4  Board of Health and Public Health Priority Setting Methodology  5  The Community’s Priorities via Crowdsourced Survey  .6  Understanding the Culmination of Board, Department, and Community  Priorities  9  A Roadmap Toward 2022 in Plymouth:   10  The Board and Department’s Action Items   10  Summary and Concluding Remarks   14  Appendix 1:  . 15  Initial Understanding of Our Public Health Priorities of Interest   15  Appendix 2:  . 17  Assessing our Public Health Priorities   17  Appendix 3:  . 19  Condensed Priorities of Interest for the Board and Department to Focus On   19  Attachment 1:   21  2017 Department of Public Health Assessment  . 21      2      26 Court Street Department of Public Health 508-747-1620 ext 10118 www.PlymouthPublicHealth.com May 22, 2019 Dear Community Member, This is the first strategic plan developed by the Town of Plymouth Board of Health and Public Health Department It represents a tremendous step and commitment for 21st Century Public Health in the Town of Plymouth We are proud to be in collaboration with many community stakeholders and community-based organizations that promote healthy lives in Plymouth Our main goal is to ensure a healthy population in Plymouth across the life course It is our commitment to modernize and professionalize in order to reach our goal for you, a stakeholder in this community We can accomplish this through community engagement that utilizes the core Public Health functions of Assessment, Policy, and Assurance while being able to provide the 10 Essential Public Health Services Birgitta Kuehn Chair, Board of Health This strategic plan is used by the Board and the Department to meet our main goal We want to ensure that conditions are established to benefit all Plymouthians and its visitors in an equitable fashion We hope you enjoy and please not hesitate to reach out to either the Board or the Department if you have questions, concerns, or general inquiries Sincerely, Birgita Kuehn, LP, MBA, CCP Emeritus Board of Health Chair 26 Court Street Plymouth, MA 02360 Dr Nate Horwitz-Willis, DrPH MPH, MPA Director of Public Health 26 Court Street Plymouth, MA 02360 3      Plymouth Public Health at a Glance Public Health 1.0 Yearly Activity and Future Priorities  On February 13, 2019, the Department of Public Health and Board of Health conducted a  brainstorming session, facilitated by Lee Hartmann Director of Planning and Development,  to identify their priorities to help develop a strategic plan and roadmap leading up to 2022.  Several citizens attended the meeting and were encouraged to participate, in addition to  community participation occurring on the internet with an online crowdsource survey. The  Public Health Department is achieving Public Health 1.0 activities well and the next step is  to move toward Public Health 2.0 and then 3.0 with the involvement of inter‐ departmental and inter‐board collaboration. Indicated below are the Public Health 1.0  activities that show the Public Health Department’s 2018 activity at a glance.                               Public Health 1.0 Operations at a Glance for Calendar Year 2018 • 5813 - Septic System Pump-outs (logged and tracked) • 2006 - Requests for septic as-built plans (39/week) • 644 - to 3-year Title Certifications (logged and scanned) • 420 - License renewal notices sent with FOG Registration notices • 740 - Burial permits released and maintained • 392 - New Title permits issued • 389 - Food inspection reports and invoices • 673 - Septic System final Inspection and Perc Tests conducted • (Includes 388 final inspections / 285 percolation tests) • 123 - Housing complaints logged and researched • 15 - Pre-Housing Inspections • 52 - Pool, camp & school inspections (when in season) • 190 - Farmer’s Market, One Day Permits, etc • 22 - New Restaurant & Retail Review and opening inspections “The Public Health Department is achieving Public Health 1.0  activities well and the next step is to move toward Public  Health 2.0 and then 3.0 with involvement of inter‐departmental  and inter‐board collaboration.”  4        The focus of the brainstorming session and discussion at the February 13th Board of Health  meeting served as an extension to the prior Town Manager commissioned Public Health  consultation report by external consultants in 2017 (see Attachment 1). The development  of a strategic plan and roadmap is a deliverable arising from that report. This strategic  roadmap and plan can be used to assure the public, within the Town of Plymouth, that the  Board and Department are moving in a direction to ensure 21st Century Public Health is  optimally provided in the municipality for years to come. A target date of 2022 sets the  stage for future comprehensive engagement of this strategic plan and roadmap.     Board of Health and Public Health Priority Setting Methodology    At the February 13th meeting the Board and the Department were asked 4 questions to,  collectively, help generate momentum forward to help develop this strategic planning and  roadmap document. The 4 questions were:     What are we doing well?  What can we do better?  What new public health initiatives should we focus on?  In the coming years, what do you see as the major public health issues confronting  the communities across the Town of Plymouth?    A total of 42 items as focus area issues were identified by the group in the February 13th  meeting. The group was then asked to prioritize these items. This report tabulates the  findings of the brainstorming session and combines it with the online crowdsourcing  survey results to create this  “The Board of Health and Department  strategic planning  of Public Health will use this living  document. The Board of  document to prioritize key activities  Health and Department of  Public Health will use this  between 2019 – 2022.   living document to prioritize  key activities between 2019 – 2022.  This document will be adapted accordingly in 2022.  Ideally it can be used as a benchmark to facilitate future planning of emerging public  health issues leading up to 2030.   5      The items identified during the brainstorming session were examined by rank in each  category (See Appendix 1). The items were then combined and ranked by overall  importance (See Appendix 2). The ranking was further refined by combining similar items  to create the final prioritized list of public health issues pertinent to the communities that  may be impacted across the Town of Plymouth (See Appendix 3).    The top priorities identified on February 13th were:   Increase in staffing and the budget to reflect growing population health issues  Provide training, better use of technology and automation of non‐skilled tasks  Establishing public health solutions to address the opioid crisis epidemic  Assessing the potential impacts of climate change on the public’s health    The Community’s Priorities via Crowdsourced Survey  A survey was provided on the Public Health website (www.plymouthpublichealth.com) for  all interested residents and visitors of the Town of Plymouth to take. The central question  asked was: What goal and/or priority would you like to see implemented in 2019 by the  Town of Plymouth Board of Health and Public Health Department?  Plymouth does have a  sizeable seasonal community. During the spring and summer months the population can  reach an estimated size of up to 100,000 according to data from Destination Plymouth.  Therefore, it was vital to capture input in this fashion. A total of 154 responses were  collected between January 20th and March 12th. There were 8 items that respondents  could select (see Table 1), however each respondent could only select up to three items to  place in three categories. The three categories prioritized each respondent’s interest as  either very interested, moderately interested, and least interested in terms of what public  health issue a respondent cared about the most for the Board and Department to address.      The central question ask was: “What goal and/or priority would  you like to see implemented in 2019 by the Town of Plymouth  Board of Health and Public Health Department?”      6      Table 1: 8 Items in the Crowdsourced Survey  Ensuring Healthy Waterways  Ending the Opioid Epidemic  Smoke Free Public Lands/Places  Needle Disposal Kiosks  Improved Activity Spaces that Promote Physical and Brain Health  Affordable Healthy Housing  Community Health Education about Marijuana and Vaping  I have another idea and will email the Director of Public Health!    Figure 1. Bar Graph Representation of Public Health Items to Address by Interest          The community appears to have prioritized healthy waterways and ending the opioid  epidemic as the two goals of most interest for the Board and Public Health Department to  benefit the public’s health within the Town of Plymouth.    A clearer picture of each category of interest is further broken down to provide a  distribution of the public health items, by percentage. This breakdown can allow the Board  and Department to then understand, quantify, and prospect how much do people, who  live in and visit the Town, care about a specific public health issue that has not yet been  adequately addressed according to the survey.          7          Figure 2: Community Public Health Goals and Priorities – Very Interested Category         Figure 3: Community Public Health Goals and Priorities – Moderately Interested Category          8      Figure 4: Community Public Health Goals and Priorities – Least Interested Category  Based on the analysis of the community crowdsourced survey the top goals and priorities  the community indicated according to the three categories are:     Healthy Waterways  Ending the Opioid Epidemic  Ensuring Smoke Free Public Lands/Places    Understanding the Culmination of Board, Department, and Community Priorities  The findings from the brainstorming session and community survey indicate how the  Board and Department can begin to strategize for the Public Health 2.0 and 3.0. Some of  the information overlaps, but it all can be used to benefit the communities across the  Town of Plymouth. The Board and the Department will utilize two tools, inherent in the  goal setting and action steps below, shown to benefit a community’s health based on  Public Health Science and Best Practices:     Address the Social Determinants of Health to ensure equitable and optimal health  When collaborating, use a judicious and balanced ‘Health in All Policies’ approach     The two concepts are effective and useful in collaboration with other Town Departments,  community stakeholders, and community‐based organizations to address what the  community wants and needs regarding living a healthy life in the Town of Plymouth. The  concepts are incorporated in the roadmap for the Board and Department to follow.    9      A Roadmap Toward 2022 in Plymouth: The Board and Department’s Action Items  This Roadmap Toward 2022 in Plymouth for the Board and Department’s action items take  into consideration how to best serve the community with the coordination and  collaboration of our stakeholders and all community members. It is realized that  leadership and support will occur from key specific groups and agencies to help ensure the  Town of Plymouth populace is healthy. There are total of 6 Road Map Item’s that have  strategic action steps for the Board and Department to follow    Road Map Item 1 Budgetary and Staffing Requirements    The Town is currently confronted with a range of public health issues that involve the  prevention of foodborne illnesses and environmental contamination exposures that  involve proper permitting to preventing chronic health and injury by helping to address  the opioid epidemic. Facilitating effective management strategies that work within the  Department of Public Health and between the Board can lead to effective Public Health  outcomes as well.     Goal: Establish Public Health Staff expectations that will facilitate the achievement of  systematic public health surveillance leading to effective collaboration among the Board.  Budgetary and Staffing Strategic Action Steps • Engage with Community to determine how to meet needs with staff • Assess budgetary and staff constraints on an annual basis • Collaborate with other Departments to address staff shortfall assistance • Create data driven staff scheduling to address growing public health issues • Evaluate the need for overtime funding for night and weekend emergencies o May involve health complaints, food festivals, and outbreak investigations • Determine how to use community host agreement impact mitigation fees • Explore other revenue sources that impact the public’s health and municipality o May include sources from Air B-n-B’s, Sugary Sweetened Beverages, etc Department and Board Involvement  Department of Public Health and Board of Health  Department, Board, Legislative, and Community Action Step Support Involvement  Committee of Precinct Chairs, Select Board, and Town Meeting   10    Finding and Recommendations Summary of Findings The authors conducted a detailed assessment of the staffing configuration, office operations, filing system, community interactions and workload at the Plymouth Health Division General findings revealed a department which is understaffed and undertrained to adequately serve the environmental health and regulatory responsibilities of the Town In addition, the PHD is largely unable to advance any of the other community health protection and health promotion activities which a functional local health department should implement Simply put, the PHD is not able to undertake appropriate efforts to improve the health status of the residents of its community as would be expected Operational Analysis Currently the health director, health inspector, animal inspector, the two (2) Title consultants and the one (1) food consultant are responsible for well over one thousand (1,000) food service inspections and a similar number of soils evaluation and septic system construction inspections per year This number does not take into account re-inspections that are required due to non-compliance and unanticipated circumstances which arise such as complaint investigations and emergency call response All this is compounded by the travel time required to navigate a community of over one hundred (104) square miles We believe the PHD would best be defined at this time as achieving a “failure to perform” status This is primarily due to the overwhelming burden of work and the lack of properly trained and sufficient staff to meet the myriad responsibilities of a quality local health department The PHD is deficient in its state and local environmental health program implementation as well as the other core responsibilities which are currently not being implemented including emergency preparedness, public health education, and various ongoing community health programs The health director cannot adequately provide the needed services and leadership which is expected for a community of this size if he or she is not able to act in a proper administrative role Currently, the health director’s job description outlines an array of environmental health inspections that must be performed in addition to a myriad of administrative duties Given the population size of Plymouth, the volume of environmental health, community health and emergency preparedness responsibilities it is not feasible to assume that the health director will be able to participate in field inspections on a regular basis The foundation of an efficient service delivery system is the processing and managing of applications and payments through a smooth flow path A review of administrative files, in conjunction with an assessment of programmatic and administrative functions and duties reveals the lack of an organizational framework that would assure that core administrative tasks and functions such as filing and monthly staff/consulting meetings are being properly managed 17 This assessment revealed that administration of environmental health programs alone requires the processing of a large number of permit applications each year This workload places an inordinate burden on the administrative staff of 1.5 full time equivalents and field staff of full-time employee, several part-time employees and part-time consultants (note that a new health director has been retained just prior to completion of this assessment) Within the town government structure, the PHD seems to operate independent of the Inspectional Services Department, with little interaction with the Selectmen-appointed Board of Health and seemingly with little interaction with other town departments Accordingly, it seems a sense of dejectedness and isolation has pervaded the PHD operations with the goal of trying to manage the sheer volume of applications having become the primary thought process Attention to detail, follow up to problems, planning new initiatives or any other type of advancement is simply not present Our assessment revealed that the PHD has limited involvement in emergency preparedness, tobacco control and community health initiatives which are mainly delivered via the MA DPH programs and local community stakeholders Nationally, local health departments the size of Plymouth are embarking on pre-accreditation and re-accreditation planning endeavors In doing so these municipalities assure their residents that they are a fully functional health department that have developed and implemented Community Health Assessment (CHA), Community Health Improvement Plan (CHIP) and a Strategic Plan in order to implement, deliver and sustained professional public health programs Currently the PHD has not embarked on any of these three initiatives Recommended Staffing Levels Increased staffing levels would allow the PHD to administer the more than eighteen (18) state and local environmental health regulatory programs, assist with the implementation of state required emergency preparedness and tobacco control deliverables and to develop and deliver ongoing and new community health initiatives Doing these would fulfill the core functions and 10 essential services required of a fully functional and operational local health department For a community of its size, the PHD should exist as its own entity rather than as a Division of the Inspectional Services Department A standalone health department must have adequate numbers of qualified staff to handle the complexities of state and local mandated environmental health responsibilities as well as the important proactive health planning and promotion activities which should be part of its operations Ultimately, national accreditation should be pursued as an operational goal A suggested path and timeline towards this is provided in Appendix B Based on the observed services needs of the Town of Plymouth and experience with comparably-sized communities, a proposed Plymouth Health Department staff chart was developed and is offered in Appendix B A description of the key job responsibilities which are envisioned in that chart are provided below:  A full-time Chief Environmental Health Officer/Assistant Public Health Director and a Chief of Community Health position would assure proper day-to-day oversight of administrative, 18    environmental and community health staff and programs while allowing the health director to focus on core functions and essential services Three (3) proposed Environmental Health Specialists (health inspectors) would ensure that plan reviews, mandated inspections, re-inspections and administrative letters are completed on time Given the size of Plymouth it is appropriate to assume that each inspector will be assigned a geographic region A Title and a food consultant could serve to alleviate the large burden of comprehensive inspections and field work for these two programs The vast array of programs outlined in the community health, tobacco and emergency preparedness section of this report would require a full-time Chief of Community Health and a full-time Public Health Nurse The continued role of the Animal Inspector is central to the core functions of the PHD The new position of Office Manager would greatly assist with the development and administrative foundation needed for the coordination of multiple environmental and community health department programs, grant management, and the development of strategic planning needed to assist the health director with ongoing program implementation and development An administrative assistant would provide full-time support to the Office Manager Finally, it is worth noting that a number of health departments throughout the country are leveraging the academic and practical expertise of schools of public health at the undergraduate and graduate level This Academic Health Department model (AHD) allows cities and towns to leverage the expertise required for grant and non-grant public health program development while significantly reducing municipal budget appropriations for these services CHA, CHIP and strategic planning are often done in concert with non-governmental organization and public health academic institutions Additional information related to AHD is contained in the following link http://www.phf.org/programs/AHDLC/Pages/Academic_Health_Department_Learning_Community.asp x Board of Health and Health Division Staff Credentials The Plymouth Board of Health members should take advantage of available training resources that present an overview of local public health law and best practices including the completion of online Local Public Health Orientation courses offered by the Local Public Health Institute at Boston University, and the Board of Health Certificate program offered annually by the Massachusetts Association of Health Boards (MAHB) Environmental health program staff (Chief of Environmental Health, Environmental Health Specialists, and environmental consultants) should have, at a minimum, a bachelor’s degree (Master’s degree preferred for Chief of Environmental Health) in public health, environmental health, biology or chemistry and should be a Registered Sanitarian/Registered Environmental Health Specialist (RE/REHS), a Licensed Soil Evaluator (LSE), a Certified Pool Operator (CPO), be ServSafe certified and be a Licensed Lead Determinator The Chief of Community Health should at a minimum possess a Master’s of Public Health or related degree The Public Health Nurse should have a background in municipal public health, 19 communicable disease reporting experience and experience in emergency preparedness and health promotion and be a registered nurse The Office Manager should have an Associate’s Degree and experience in municipal office operations, staff supervision and grant management Environmental Health Recommendations A representative amount of environmental health programs were reviewed to determine if state and local regulatory mandates including applications, plan review and required inspections were being properly followed This review included the following environmental health programs and regulations: food establishments, housing & nuisance, swimming pools, recreational camps, stables, tanning and body art, and Title (onsite wastewater) The review revealed that required comprehensive inspections and re-inspections were not being conducted as demonstrated by years of missing inspection reports Documents in the files surveyed were often missing, incomplete, or not in chronological order thereby adding to the difficulty of file review PHD staff and consultant coordination, and overall attention to paperwork detail was found to be mediocre and could stand for improvement Food Program PHD staff (field and administrative) and the food consultant should have Standard Operating Procedures (SOPs) for all inspection based programs and the administrative functions that support the food service program Field staff should also have, at a minimum, the following credentials: Registered Sanitarian/Registered Environmental Health Specialist, ServSafe certificated, MA DPH Allergen Training certificate and demonstrate proficiency in Microsoft Office software program A cross-cutting responsibility for administrative staff and field staff (e.g health agents, sanitarians) is to ensure that all permit applications are received and completed prior to the issuance of a permit and/or the initiation of a field inspection All food service inspections, including but not limited to, food service, retail and temporary food events should be pre-assigned to the health agent/inspector and food consultant on a monthly basis to ensure annual completion of mandated inspections To increase efficiency, food service establishment inspection lists are often assigned by geography (i.e., district) to limit unnecessary travel The food service consultant contract should include a monthly debrief meeting with the health director, health inspector/sanitarians to discuss completion of assigned inspections, the status of licensed establishments compliance with the food code and to recommend reinspections and possible administrative actions such as orders to correct and administrative hearings PHD inspectors should conduct food establishment reinspections to determine compliance with the food code and when an order letter and/or administrative action should occur as a result of serious and repeated violations A food inspection SOP should be created to address the proper completion of a food establishment inspection report/protocol so that a standard inspection is implemented and maintained between the consultant and health department field staff The SOP, at a minimum, should address the conduct of the inspection listing of areas inspected within the licensed establishment and the language used to describe violation and the specific requirements of the inspection exit interview 20 Additional field staff are needed to complete the required number of inspections for the recorded 320 food establishment inspections and 198 retail food inspections As a general rule there should be no more than 100 food establishments (food service and retail) assigned to a full-time inspector since field staff often have multiple state sanitary code and local environmental health education and enforcement responsibilities Field staff should also be avail themselves of ongoing training provided by the Massachusetts Environmental Health Association (MEHA), Massachusetts Health Officer Association (MHOA) and the Local Public Health Institute (LPHI) to ensure attainment of evolving practice standards The PHD has numerous food service permits such as food service, retail food, milk & oleo and frozen desserts Milk and oleo and frozen dessert permit should be included under the retail food permit The inclusion of these permit under the retail food permit would save a significant amount of administrative time that is currently spent on processing these applications and in the acquisition of these fees Housing and Nuisance Program PHD should develop a separate hard copy and electronic complaint registry (separate worksheets if the data is recorded in excel format) that lists pertinent data for all nuisance and environmental health (state sanitary codes and local regulations) complaints Intake data should include: date of complaint, name of complainant, nature of complaint, inspection date, order letter issued, status of case (court action/BOH hearing/abated) and inspectors initials Anonymous complaints should be recorded and inspected A hoarding task/problem property task force should be developed and consist of representatives from government and non-governmental organizations including but not limited to, fire, police, building, health department, housing authority, social service agencies and council on aging The PHD should consider a pre-rental housing inspection regulation to support safe living conditions for all tenants/occupants Several Massachusetts local boards of health have a local pre-rental regulation and/or ordinance that may serve as a template for the PHD’s consideration Body Art Program Annual application packets should be mailed to each licensed establishment to ascertain compliance with regulatory requirements Applications packets, at a minimum, need to include operator and practitioner information, address of establishment, owner contact information, copies of current practice certificates, required medical information and training certificates and other documentation identified in the regulation Once a complete application packet, with fee(s), is received by the PHD a permit to operate and a practitioner(s) permit may be issued A completed application packet will ensure that minimum establishment requirements, operator and practitioner standards are in compliance Practitioners must be linked to an approved facility and that information (specific address) should be recorded on the practitioner’s permit Prior to a routine or complaint inspection, PHD inspectors should review the file to understand the “profile” of the establishment as it will influence the focus of the inspection Body art establishments should be inspected twice a year in order to assure compliance with regulatory standards A review of previous inspection reports will assist the inspectors with future inspections and may reveal the need to pursue administrative actions should serious and repeated violations persist In addition, inspectors and 21 administrative staff may identify missing documentation in the file under review which will assist in the attainment of required documentation New establishments should go through a detailed plan review process that assures compliance with required standards outlined in the regulation Plan review packets should be designed to guide prospective establishment owner/operators with establishment requirements, required certification documents and the need to interface with additional municipal departments that have regulatory purview Prior to completing a file review a plan review checkoff list should be completed to assure that all required information and documentation is received prior to issuance of a permit to operate Swimming Pool Program Annual and seasonal application packets should be mailed to each licensed pool to ascertain compliance with regulatory requirements Annual pool renewal application packets should be mailed to current permit holders in November with a follow-up mailing (if necessary) in December to assure that regulatory compliance is attained prior to the start of the annual permit season which should begin January 1st of each year Seasonal pools are typically outdoor pools, wading and special purpose pools that are generally opened for operation after Memorial Day These pools generally cease operation after Labor Day Seasonal application packets should be mailed to licensed pool facilities by March of each year with a follow-up mailing (if necessary) in April to assure that pools are ready to open in May or June Swimming pool application mailing and review and inspectional efficiencies are enhanced by separating permit renewal dates for annual and seasonal pools within the calendar year Each licensed pool should be inspected monthly to ascertain compliance with pool chemistry standards and safety requirements Annual or semi-annual education seminars should be offered by the PHD to assist permit holders with compliance requirements Inspectional staff should attain certification as a Certified Pool Operator (CPO) Tanning and Recreational Camp Program Tanning establishments should be inspected twice a year to ensure compliance with the state regulation Annual application packet should include appropriate establishment data such as address, contact information, documentation requests including but not limited to, consent forms for clients, warning signage, appropriate training of staff to determine skin type and any medical conditions, including medications that would preclude clients from tanning New establishments should undergo plan review procedure that requires applicants to submit, at a minimum, a detail floor plan that depicts the location of tanning beds, signage, staff training, temperature recording devices, ventilation and equipment repair/replacement procedures Recreational camps, due to their regulatory complexity, require substantial oversight to ensure compliance with policies, procedures that often require significant plan review and inspectional demands on local health departments Accordingly, prior to pre-operational camp inspections, the PHD should offer educational in-services to returning and prospective camps operators in order to assist them with plan review and application compliance requirements including but not limited to, emergency procedures, criminal and sexual records checks (CORI/SORI), immunization status of campers, food code 22 requirement, beach and swimming pools requirement and Christian’s Law Most municipal camp inspections require the involvement of the health director/agent, public health nurse(s) and on or more environmental health inspectors Stable Program The “Rules and Regulations Governing Horses and Stables” program would benefit from reformatting/amending the regulation to include plan review language that is linked to specific plan review document submission These documents, at a minimum, would include onsite waste water (Title 5) plans, state regulatory requirements, zoning requirements and specific state regulatory language in addition to specific land maintenance practices A comprehensive “model” plan review example would serve as a guide for the applicant A hardcopy version and the regulation would include appendices that would address the aforementioned plan review requirements The electronic version of the regulation/application documents may contain hyperlinks that refer the applicant to needed resources A plan review checklist would help to ensure that required plan review documents are submitted and reviewed prior to the granting of a permit Title (Onsite Wastewater) Program The PHD manages a high volume of processes and procedures related to onsite wastewater For example, in 2016 there were 374 new or replacement septic systems built Each one of these involved soil testing, plan review and construction inspections and some might have also involved other processes including system inspections, tank pumping, deed notices, well testing or other aspects Each one of these involvements is an opportunity to assure compliance with minimum standards in the Massachusetts Environmental Code, as well to assure proper design, installation and long-term maintenance occurs The sheer volume of “touch points” (pumping, system inspections, soil evaluations, design plan review, permitting, construction oversight, project close-out and long-term operation and maintenance), the different audiences who are involved at different times of the process, the complex nature of subsurface sewage treatment, and the geographical constraints of a 104 square mile community with the septic systems located at the outlying parts of town combine to make this a difficult program to properly operate The environmental sensitivity of the approximately 400 waterbodies in Plymouth, the public health risk of many houses served by private wells plus the generally sandy and rapidly percolating soils which provide poor removal efficacy of contaminants all combine to warrant the need for a greatly enhanced operation Standardized procedures need to be developed and implemented, variances and local upgrade approval review standards need to be applied, regulations need to be revised or eliminated, and a comprehensive assessment of wastewater treatment in Plymouth’s soils needs to be performed to assess the impacts to drinking water wells and ponds Overall we found that the many people involved both within the town and representing a property owner combined with the fragmented record-keeping system and other operational problems has lead to a program with some weaknesses 23 Operations Great effort went into scanning historical plans and records which could be a great customer service tool This document scanning initiative stopped several years ago with the resulting paper filing system growing unmanageable for the small office space Paper files are stored in boxes and drawers, as well as in digital format, making for challenges to access and utilize the information comprehensively Databases are maintained regarding pumping and system inspections going back 10-20 years but they are not analyzed in any manner nor they provide any useful information to the consumer A database exists associated with all system installations but the ability to identify unique septic system features (such as the need for routine annual preventable maintenance) was not consistently input making the data unreliable “Commercial” projects are stored and managed differently from single family house projects, but it is not certain what heightened level of scrutiny these project might or might not receive The physical work of witnessing soil testing and performing construction inspections is performed by outside consultants The volume of work necessitates their services on an almost full-time basis For example, on one recent day there were soil test witnessing events and construction inspections scheduled to be implemented by the town’s consultant The consultant seemed very pressed for time due to travel and the need for recording relevant documentation There are some 300-400 soil tests performed and systems installed in a typical year The sheer volume of this activity cannot reasonably be managed by one outside contractor even with the clerical assistance that is currently provided There are two persons under contract to work on onsite wastewater issues, though only one appears active at this time The contractor implementing the onsite wastewater program seems to have considerable experience with which to draw, which is an invaluable benefit However, the entire review and oversight process seems to be oriented towards reducing regulatory hurdles and not implementing the protocols that are specified in the regulations or are otherwise good practice Greater documentation and conformance with regulatory standards would result in the appropriate provision of Title compliance for proposed system soil evaluation, plan review, installation and oversight Local regulations and policy documents almost uniformly refer to Title of the Massachusetts Environmental Code as “Title V” While this is solely a typographical error that continues to be repeated, it also represents a lack of understanding of even the basic aspects of onsite wastewater management when the state code regulatory citation is not used correctly Guidance documents regarding procedures for various aspects of onsite wastewater system projects are contained in a document entitled “Town of Plymouth Board of Health Rules and Regulations” revised May 12, 2017 It is doubtful these guidance documents are actually regulations, nor is it advisable to have them made into regulations The Board of Health has regulations addressing onsite wastewater many of which duplicative with Title or otherwise are not written to contemporary standards A comprehensive review of these regulations would 24 be prudent For example, one section of the Plymouth Board of Health Rules and Regulations is titled “Installers and Title V (sic) Inspectors” yet the text beneath the heading refers to procedures for obtaining a variance While not directly related to the onsite wastewater program, it is worth noting that there exists a Board of Health Regulation entitled “Fats, Oil, & Grease (FOG) Pretreatment Systems” for establishments which discharge to the town’s sanitary sewer system This regulation was adopted in addition to the Town of Plymouth’s Sewer Use Rules and Regulations It is unclear if the enforcement of this regulation rests with the PHD or the sewer department staff, nor which entity has been trained and authorized to implement this regulation No comprehensive plan exists to protect surface water quality around the hundreds of ponds in Plymouth or the groundwater quality in areas served by individual potable wells This is not required in Title of the Massachusetts Environmental Code however if developed would provide a method to best protect drinking water and overall water quality This is especially important due to the almost universal presence of rapidly percolating sandy soil conditions which typically does not provide ideal treatment of effluent as it migrates through the soil column Design Review No checklist exists for reviewing design plans against regulatory standards and prudent engineering principles As a result, compliance issues can be missed and uneven procedural matters can occur depending on the applicant or their representative For example, a randomly selected approved design plan showed flow coming from a distribution box into two trenches of unequal length This is a basic conflict with Title and which should have been required to have been adjusted prior to approval Details which are required to be noted on the plan or included with a submission by the designer are often absent Random plan examinations showed these omissions included: not noting Local Upgrade Approval requests on the design plan, a notation specifying use of a poly tank but no approved brand or model being specified, no inspection port location being indicated, a waterline located beneath the leaching area with no variance request, and no designer certification for use of a particular leaching system as required The review standards identified in Title for variances and Local Upgrade Approvals not appear to be applied by the staff or Board of Health, which can lead to weakened environmental health protection Additionally, when an onsite wastewater design plan does not comply with the regulations and is seeking a Local Upgrade Approval or a variance, this review process is administered solely by the consulting staff (with the exception of the limited instances when Title requires the relief to be brought to a public hearing before the Board of Health) No information exists as to how this policy of staff-level review was developed or if it was endorsed by the Board, nor is it clear what parameters are used by the consultant to decide to issue or not issue such approvals and variances Finally, it seems incongruous that when there is actually a hearing before the Board of Health for a Local Upgrade Approval or variance, the consultant or 25 staff member most familiar with the project site and who has reviewed the design plan is not asked to attend the Board of Health meeting to provide context There is no mechanism to deal with public health risks to wells or waterbodies, with little to no regulatory push to require enhanced systems in sensitive areas Construction Oversight A septic system installation checklist is available and seems to be regularly used However, it does not account for system types other than basic stone-and-pipe, even though most of the systems no longer use this disposal mechanism To overcome the workload volume and limited staffing the PHD requires a construction inspection and as-built plan to be prepared by the designer before they complete their final inspection This can be a useful mechanism to have construction deficiencies identified and remedied by others without involving time of the staff or consultant The process to become a licensed septic system installer does not involve any degree of scrutiny beyond showing licenses in other communities and proof of insurance The only required demonstration of competence is a self-certification which is required to be completed on the application form whereby an applicant attests they are capable of reading engineering plans No written or field examination is required for licensed individuals Maintenance Non-traditional systems which need to have deed notices or routine maintenance performed are not tracked or managed in any comprehensive manner aside from occasional notes on a database and physical retention of some paper files in a part of one drawer of a filing cabinet All system inspection reports are both scanned and also saved in paper format The lack of a document management system is overcrowding the usable working space in an existing small office set-up Community Health Recommendations Public Information and Community Engagement Activities Update the PHD website: Health departments, like all government agencies, increasingly rely on their website to provide both critical and routine information for the public The PHD website should be upgraded to include the following: a 24/7 emergency contact information including after hour phone numbers for a health department on call officer, or refer callers to 911 to be connected with city officials in an emergency Contact information should also be provided for the afterhours contact information for the MA DPH Bureau of Infectious Disease b Provide information to the public on a wide range of public health issues including infectious disease, health promotion activities, and substance abuse treatment and prevention posting information directly on the site or by including links to the corresponding MA DPH and CDC websites 26 c Public health data on the incidence of disease and other public health concerns should be displayed on the website including links to relevant DPH sites and posting of the Beth Israel Deaconess Community Health Needs Assessment Provide additional written information on public health issues: PHD should procure written materials in relevant multiple languages on public health issues of concern in the town The information can be available for distribution in the PHD office, other locations in Town Hall, and distributed to other town offices, including the school department PHD staff can sponsor or participate in health fairs or other community events that present opportunities to directly engage the public on health matters Join and become active in the Healthy Plymouth Coalition: PHD can immediately expand its contacts and engagement with the community through active participation in the existing health coalition that supports healthy lifestyle activities in Plymouth Utilize public health data to inform PHD activities: The Board of Health and PHD staff should review the findings in the 2016 Community Health Needs Assessment conducted by Beth Israel Deaconess Hospital Plymouth Utilize the media: Increase resources devoted to engaging the community on health promotion efforts via the local media by distributing press releases and seeking out broadcast media opportunities such as radio talk shows, cable access shows, and online media opportunities Increase utilization of social media to distribute information to town residents Tobacco Control Enforcement: Continue to collaborate with the CCRTCP to enforce tobacco control regulations for sales to minors, advertising and display regulations, enforcement of the workplace smoking law Continue timely distribution and collection of violations cited by CCRTCP and forwarded to PHD for notification, collection of fines, and further action when necessary such as license suspension for repeated violations Regulations: Update the town tobacco control regulations consistent with model regulations currently supported by the MA Tobacco Control Program including: a Increasing the minimum purchasing age to 21 b Banning the sale of flavored tobacco c Banning the sale of blunt wraps d Banning the sale of cigars that retail for less than $2.50 Community Health Surveillance Surveillance: Continue to support health reportable disease surveillance conducted by a qualified public health nurse MAVEN: Continue to submit reportable disease data to MA DPH via the Massachusetts Virtual Epidemiological Network (MAVEN) 27 Emergency Preparedness Participate in regional preparedness groups: PHD should resume active participation in the Region HMCC and the Plymouth County Public Health Coalition, including attendance at meetings and participation in regional emergency exercises Update emergency plans: Update all public health emergency plans to include staffing responsibilities, including names and contact information within the plans Exercise emergency plans: Conduct annual exercises of the Emergency Dispensing Plan and a rotating series of exercises of other emergency plans, including call down drills to test PHD and other town staff on afterhours response times Emergency volunteers: Reestablish a Medical Reserve Corps Unit or collaborate with the Town Emergency Manager to organize a trained CERT team to ensure Plymouth has access to a cadre of trained volunteers to respond in emergencies Consider engaging retired emergency planner Sandra Landry to help with planning and exercises Incident command: In order to effectively participate with other emergency responders, all PHD staff should be trained in the ICS system, at a minimum through the third level (ICS 200) Grant Opportunities and other External Supports for Public Health The Town of Plymouth should investigate opportunities to support public health activities through application for state, federal, and private grant opportunities The MA Department of Public Health regularly issues Requests for Responses for grant and contract opportunities to provide public health services for substance abuse treatment and prevention, community-based nutrition and fitness enhancement, violence prevention, chronic disease prevention, and other public health programs LHDs are eligible for many of these and in some cases are the only eligible applicants National organizations such as the National Association of City and State Health Officials (NACCHO) offer grant opportunities that serve to improve local health services, for example they administer a program that offers small grants to support local health departments preparing to apply for accreditation from the Public Health Accreditation Board (PHAB) NACCHO and the National Association of Boards of Health (NALBOH) run conferences and trainings available at low or no cost to local health departments Federal grants supporting local health are available through the CDC, FEMA, and other agencies, often administered by state agencies such as MA DPH and MEMA 28 Acknowledgements The authors thank the following individuals for contributing valuable information and insight into this report Melissa Arrighi, Town Manager, and Paul McAuliffe, Director of Inspectional Services, supported the assessment process and provided crucial contextual information about municipal operations in Plymouth and the Health Division’s role within municipal government Former Assistant Town Manager Derek Brindisi made time available for consultation on the assessment subsequent to his departure Board of Health Chair Steven Striar and current health division staff Karen Keane, Health Inspector; Krista Lewis, Administrative Assistant; and Marilyn Fiston, Senior Clerk greatly assisted by sharing information about current Board of Health and PHD operations PHD consultant Robert Tinkham assisted with the Title program assessment The following individuals contributed valuable information to the community health section of the report: Henry Lipe, Director of Emergency Management; Veronica Kordis, RN, Public Health Nurse; Robert Collette, Director of the Cape Cod Regional Tobacco Control Program; Sandra Landry, Regional Emergency Planner (retired), Plymouth Public Health Coalition; Brian Gallant, Program Coordinator Region Five Health and Medical Coordinating Coalition; and Andrea Holleran, Vice President Beth Israel Deaconess Hospital Plymouth Methodology This report was compiled by the authors based on extensive review of current Plymouth Health Division operations, staffing, files and other records, and using interviews with municipal officials, contracted service providers and community members Additional research and information was compiled from state and national public health organizations to provide context and comparison in order to formulate recommendations for improvement of public health services in the Town of Plymouth About the Authors This assessment report was completed as a collaborative effort by three former municipal public health department directors Steven J Ward, MA, MPH/REHS, has served as the Deputy Director of Public Health for the City of Worcester and the Director of Public Health for the Towns of Braintree and Watertown, Past President for the Massachusetts Environmental Health Association (MEHA) and currently serves as an adjunct professor teaching public health at Worcester State University Mr Ward also serves as a Council on Education for Public Health (CEPH) in the capacity of a practitioner site visitor Michael Coughlin, MS, is the former Director of Health and Human Services for the City of Fall River, most recently served as Accreditation Coordinator for the MA Department of Public Health, is an Adjunct Instructor of Human Services at Bristol Community College and a site visitor for the Public Health Accreditation Board Daniel Ottenheimer, MS, served as the Public Health Director for the City of Gloucester and currently sits on several state advisory committees related to wastewater issues 29 Appendix A A Timeline to Achieve Excellence in Public Health in Plymouth, Massachusetts The Plymouth Health Department will move forward to become a recognized leader in Massachusetts and the nation in advancing the public health of the community: 2017 ongoing Increase public health infrastructure required for a standalone health department in order to meet core functions and essential public health services 2018 2019 Convene community stakeholders to assess the health of the community, develop and begin implementation of a community health improvement plan, and a departmental strategic plan 2019 2020 Begin preparations and apply for national accreditation 2021 Achieve national accreditation from the Public Health Accreditation Board 30 Appendix B Current Plymouth Health Division Organizational Chart Director of Public Health Admin Assistant C-3 Senior Clerk Animal Inspector Local Inspector Food Consultant T5 Inspector Consultant T5 System Inspector Consultant Proposed Plymouth Health Department Organization Chart Director of Public Health Chief of Envir Hlth/Assistant Director of Public Health Office Manager Admin Assistant Envir Hlth Specialist (Inspector) Envir Hlth Specialist (Inspector) Envir Hlth Specialist (Inspector) 31 Chief of Community Health Animal Inspector FTE Pub Hlth Nurse FTE Public Health Nurse