INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 12, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on November 12, 2025, the facility failed to have hot water temperatures that did not exceed 120hallway bathroom located in the corridor to the right of the front entrance had a temperature reading of 127The hallway bathroom located in the corridor to the left of the front entrance had a temperature reading of 122
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Plan of Correction
On 11/12/2025, the Facilities Director adjusted the hot water heater to ensure the water temperature is maintained within the regulatory range. The Facilities Director will monitor and document water temperatures routinely to ensure ongoing compliance with DDAP and safety standards. |
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
During an onsite complaint investigation conducted on November 12, 2025, the facility failed to have a heating system that was adequate to maintain an indoor temperature of at least 65thermometer readings taken in the Conference Room showed temperatures ranging from 59
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Plan of Correction
Repairs to the heating elements on the two affected units have been scheduled with the HVAC contractor, DESCO. Per DESCO's guidance and in the interest of fire prevention and safety, the two units must remain turned off until the repairs are completed. Staff and clients have been notified of this temporary shutdown of the two effected heating units, and the Facilities Director will ensure the units are returned to service immediately upon completion of the repairs. Additionally, the Director of Compliance will update the monthly Health and Safety Inspection Sheets to ensure temperature checks are clearly documented and remain within appropriate ranges. Any concerns identified during monitoring will be addressed immediately to maintain safety, comfort, and regulatory compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services in one of four client records.Client # 5 was admitted on October 17, 2025, and was still an active client at the time of the complaint investigation. A treatment plan dated October 26, 2025, did not contain the types and frequencies of treatment and rehabilitation services
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Plan of Correction
The Regional Director will meet with all clinicians to provide retraining on the development of treatment plans, with emphasis on clearly documenting the type, frequency, and duration of services, as required by DDAP regulations. This meeting will also address the importance of timely completion and signing of treatment plans to ensure regulatory compliance and continuity of care. The next scheduled group supervision meeting is Thursday 11/20/2025. Going forward, the Regional Director will monitor treatment plans for accuracy and completeness to ensure sustained compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two of four client records. Client # 1 was admitted August 12, 2025, and discharged September 8, 2025. The treatment plan dated August 20, 2025, indicated there was to be at least one process group per day. There was no documentation of group progress notes between 8/1/25 - 9/8/25.Client # 4 was admitted October 16, 2025, and was still an active client at the time of this complaint investigation. The treatment plan dated October 22, 2025, indicated there was to be a daily process group. There was no documentation of group progress notes between 10/25/25 - 11/11/25.
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Plan of Correction
The Regional Director will ensure that all group notes are co-signed and posted to the medical record within 48 hours of the completed service. To support ongoing compliance, the Director of Compliance will conduct quarterly quality assurance reviews of all completed service notes to verify that documentation is signed by all required parties and posted within the 48-hour timeframe. Any deficiencies identified during these reviews will be addressed through targeted staff feedback and corrective action as needed to ensure sustained compliance with DDAP documentation standards. |