INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Polaris Detox LLC DBA Innovo Detox was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. All fire extinguishers in the facility were not inspected in the last year. The last inspection date was August, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On September 25, 2026, all facility fire extinguishers were inspected and certified by JCI, and the current inspection tags were replaced on the extinguishers. The facility will retain the service documentation and verify that the date shown on each extinguisher or tag is current. JCI acknowledged that the tags had not been replaced during its August 2026 visit.
By October 2, 2026, the Maintenance Supervisor will verify each extinguisher against the JCI service documentation and provide the completed inventory to the Executive Director. The Maintenance Supervisor will maintain a schedule for annual inspection before the next due date. The Office Manager will track the due date, and the Executive Director will review the service record and inventory annually to confirm that every extinguisher was inspected and properly tagged. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the October, 2025 through August, 2026 fire drill logs during the inspection, the facility failed to document the amount of time it took for evacuation on the May 12, 2026 fire drill log.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The May 12, 2026 fire drill record did not include the evacuation time. By October 2, 2026, the Maintenance Supervisor will review the original record and any contemporaneous documentation to determine whether the time can be verified. If it cannot be verified, the record will be annotated to identify the missing information; an evacuation time will not be estimated or entered without supporting documentation. The Executive Director will review the remaining fire drill records from the inspection period for completeness and address any additional omissions identified.
Beginning with the next fire drill, the Maintenance Supervisor will complete a paper record that includes every item required by § 705.10(d)(4), including the evacuation time. The Maintenance Supervisor will submit the record to the Office Manager within one business day. The Office Manager will check it for completeness, return any incomplete record promptly for correction based on information available from the drill, and scan the completed record to SharePoint or the facility's designated electronic records system. The Executive Director will conduct a final review of every fire drill record each month and document that review. Staff responsible for the records will be instructed on this process by October 9, 2026. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending December 31, 2024.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the October 8, 2025 licensing inspection.
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Plan of Correction
The facility acknowledges that an independent CPA financial audit for the fiscal year ending December 31, 2024 was not available at inspection. Previous ownership has advised that it will not provide that audit.
Innovo came under new ownership on September 24, 2026. R&S Holdings, Inc. engages a national accounting firm to perform annual independent financial audits. Innovo's drug and alcohol treatment activities will be separately identified in the audit documentation, beginning with the 2026 financial year audited in 2027 and annually thereafter.
The Managing Partners of R&S Holdings, Inc. are responsible for ensuring that the annual audit is completed and the required documentation is available for DDAP review.
By October 31, 2026, the Executive Director will communicate with the Managing Partners to review the DDAP audit requirement, confirm what documentation must be provided for Innovo, and obtain the anticipated audit completion date. The annual audit schedule and documentation requirements will be established and documented by October 31, 2026.
The Managing Partners will monitor audit progress with the accounting firm annually, address delays, and ensure that Innovo's completed audit documentation is provided to the facility and retained for licensing review. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records included an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee in one out of one applicable record.
Employee #2 was hired as the Clinical Director on January 13, 2025 and was still in that position at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director's annual written performance evaluation was not present in the personnel record at the time of inspection. The evaluation had been pending review by the previous corporate organization, and feedback was returned to facility leadership on September 23, 2026.
Under Project Chesapeake's policy, staff performance evaluations will be completed in January. By January 31, 2027, the Executive Director will complete the Clinical Director's written evaluation, review it with the Clinical Director, obtain the Clinical Director's signature acknowledging review, and place a copy in the personnel record. The evaluation will reflect the date it is actually completed and reviewed.
By January 31, 2027, supervisors will complete and review written annual evaluations for all applicable staff under the new company's policy. Office Manager/HR will maintain a tracker showing each employee's evaluation and review date, confirm that the signed evaluation is in the personnel record, and schedule the next evaluation no later than one year from the completed review date. Office Manager/HR will check the tracker monthly and notify the responsible supervisor and Executive Director of upcoming or overdue evaluations. The Executive Director will review outstanding items until they are resolved. |