INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2021 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #5 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #5 was hired as a support staff on August 1, 2019 and was still in this position at the time of the inspection. Employee # 5 was due to have the communicable disease trainings no later than August 1, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Innovo Detox has partnered with a training consultant who will provide the necessary DDAP trainings (HIV/AIDS and TB/STD/Hep C) to our staff in a timely manner. Employee #5 was on leave during the previous trainings, so employee #5 will be attending the next training that is scheduled for February 21 and 22, 2022. This training will also fulfill the requirement for all staff coming up on their two-year anniversary. The HR Department and the Compliance Specialist will ensure all other new staff meet the two-year requirement, unless they are in a position that requires the training within one year. The trainings and timelines are outlined on the employees training plan. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on review of The Staffing Requirements Facility Summary Report and primary care staff schedules, the facility failed to provide documentation of one primary care staff being available for every seven clients during primary care hours.
November 14, 2021 from the hours of 12am-6am there were only 2 primary staff for 16 clients and should have had 3 primary care staff available.
November 17, 2021 from the hours of 6am-7am there were only 2 primary staff for 16 clients and should have had 3 primary care staff available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Management, including our Executive Director, Director of Nursing, and Director of Human Resources and Compliance, will ensure that staffing ratios are adequate for the number of patients present in treatment. Human Resources is actively hiring for full-time and PRN nurses, and we have partnered with an agency that can provide temporary nursing staff. Admissions will be alerted if we need to cap our census. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Several counseling office doors have a frost on glass doors that provide a gap on the bottom large enough to be able to see individuals.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Innovo Detox has contracted with a company that is going to frost the gap at the bottom of the counseling room doors to match the rest of the frost already on the doors. This will make it so counseling areas cannot be seen from outside the offices. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking utensils stored in a clean enclosed area. Cooking utensils were hanging from hooks above the prep counter.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chef at Innovo Detox will purchase containers to store the cooking utensils in place of the hanging hooks. The containers will be enclosed. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of April 2021 and December 2021, the facility to provide documentation of a fire drill being conducted the month of October 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 15, 2020 licensing inspection.
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Plan of Correction
The Safety Officer will be responsible for facilitating monthly fire drills. The Safety Office will schedule the fire drills earlier in the month to leave a buffer incase a situation arises where the fire drill needs to be postponed. The Compliance Specialist will audit the fire drill documentation at the end of the month to ensure the fire drills took place. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on six of seven applicable client records reviewed, the facility failed to provide case consultation in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation will be conducted during every morning staff meeting. Case consultations were not documented per facility policy and procedure manual in client records # 2, 3, 4 ,5 ,6, and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist re-worded the Policy & Procedure for case consultations to clarify that each patient will have one case consultation documented in the patient's chart within the week of admitting to treatment. |