INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2024 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 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of fire drill logs from August 2023 until August 2024 the facility failed to conduct a fire drills on different days of the week, at different times of the day and night and on different staffing shifts as twelve out of twelve fire drills were conduct within the last four days of the month.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Compliance Director communicated with the Maintenance Supervisor who facilitates the fire drills every month regarding the timing of the fire drills. Starting in October of 2024, the Maintenance Supervisor will schedule the drills sporadically throughout the months (beginning, middle, and end) while still conducting them on different days of the week, different shifts, etc. The fire drills will continue to be documented so that the Compliance Director can audit when the drills are occurring throughout the months to ensure compliance with this regulation. |
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 residential client records, the facility failed to document type and frequency on individual treatment plans for seven out of seven client records.
Client #8 was admitted on September 4, 2024 and was still active at the time of the inspection. The treatment plan was dated September 4, 2024 .
Client #9 was admitted on September 7, 2024 and was still active at the time of the inspection. The treatment plan was dated September 7, 2024 .
Client #10 was admitted on June 18, 2024 and was discharged on June 30, 2024. The treatment plan was dated June 19, 2024 .
Client #11 was admitted on May 1, 2024 and was discharged on May 9, 2024. The treatment plan was dated May 1, 2024.
Client #12 was admitted on April 14, 2024 and was discharged on April 25, 2024. The treatment plan was dated April 14, 2024.
Client #13 was admitted on August 20, 2024 and was discharged on August 28, 2024. The treatment plan was dated August 20, 2024.
Client #14 was admitted on April 18, 2024 and was discharged on May 2, 2024. The treatment plan was dated April 18, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Compliance Director communicated with the Clinical Director, who communicated with the clinical team regarding the type and frequency missing from treatment plans. Moving forward, the clinical team will include a type/frequency with each objective in a patient's treatment plan. This will be audited when the Clinical Director signs off on every treatment plan and when the Compliance Director audits charts monthly. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of residential client records, the facility failed to document the proposed type of support services on individual treatment plans for seven out of seven client records.
Client #8 was admitted on September 4, 2024 and was still active at the time of the inspection. The treatment plan was dated September 4, 2024 .
Client #9 was admitted on September 7, 2024 and was still active at the time of the inspection. The treatment plan was dated September 7, 2024 .
Client #10 was admitted on June 18, 2024 and was discharged on June 30, 2024. The treatment plan was dated June 19, 2024 .
Client #11 was admitted on May 1, 2024 and was discharged on May 9, 2024. The treatment plan was dated May 1, 2024.
Client #12 was admitted on April 14, 2024 and was discharged on April 25, 2024. The treatment plan was dated April 14, 2024.
Client #13 was admitted on August 20, 2024 and was discharged on August 28, 2024. The treatment plan was dated August 20, 2024.
Client #14 was admitted on April 18, 2024 and was discharged on May 2, 2024. The treatment plan was dated April 18, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Compliance Director communicated with the Clinical Director, who communicated with the clinical team regarding the type and frequency missing from treatment plans. Moving forward, in each patient's treatment plan, the clinical team will develop an objective with the patient regarding the proposed type of support services. This will be audited when the Clinical Director signs off on every treatment plan and when the Compliance Director audits charts monthly. |