INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 25, 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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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 a review of client records and the Against Therapeutic Advice Discharge policy, the facility failed to follow its policy regarding informing an emergency contact when a client leaves treatment in one of four charts reviewed.Per the Against Therapeutic Advice Discharge policy, the patient's emergency contact will be notified immediately by method consented by the patient; notification should be completed no longer than 12 hours of patient leaving. At least one attempt to contact shall be made by staff. the contact attempt and/or completion shall be documented in the patient chart.Client # 1 was admitted February 25, 2025, and discharged March 13, 2025. The client record did not contain documentation of notification, or an attempted notification, to the emergency contact that the client left treatment.
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Plan of Correction
Plan of Correction
Policy Review & Training: All clinical and discharge staff will receive refresher training on the ATA Discharge policy, with an emphasis on the 12-hour notification requirement and documentation standards.
Chart Audit Protocol: Supervisors will conduct random audits of all ATA discharges on a weekly basis for the next 90 days to ensure compliance.
Responsible Staff
Clinical Director will oversee training and audit implementation.
Compliance Officer will monitor audit results and report trends to leadership monthly.
Monitoring and Evaluation
Weekly audits will be reviewed in clinical team meetings.
Any missed notifications will be addressed immediately with corrective coaching.
After 90 days, audit frequency will be reassessed based on compliance rates.
Completion Date
Training completed by: August 8, 2025
Audits begin: August 15, 2025
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documentation, the facility failed to inform the Department of unusual incidents requiring the presence of ambulance personnel, within the required three days.Internal incident reports were reviewed. Ambulance personnel were onsite 2/13/25, 2/27/25, and twice on 2/28/25. The facility did not file a written unusual incident report with the Department.
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Plan of Correction
Plan of Correction
Staff Training: All clinical and administrative staff will receive mandatory training on DDAP's reporting requirements, including timelines and qualifying events, by August 5, 2025.
Daily Incident Log Review: The Compliance Officer will review the daily incident log to identify reportable events and ensure submission within the 3-day window.
3. Responsible Staff
Compliance Officer: Oversees policy updates, training, and ERS submissions.
Executive Director: Ensures staff compliance and monitors implementation.
4. Monitoring and Evaluation
Weekly audits of incident logs and ERS submissions will be conducted for 90 days.
Any missed or late reports will be reviewed in monthly compliance meetings.
Audit results will be documented and used to adjust training or procedures as needed.
Completion Date
Staff training: August 5, 2025
Audit implementation: August 8, 2025
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in two of four records reviewed.Client # 2 was admitted to inpatient rehabilitative services on March 9, 2025, and discharged on March 28, 2025. A treatment plan was completed on March 10, 2025, and an update was due no later than March 25, 2025; however, there was no update documented in the client record. Client # 3 was admitted to detoxification services on February 23, 2025, and to inpatient rehabilitative services on February 28, 2025. Client # 3 was discharged on March 28, 2025. A treatment plan was completed on February 28, 2025, with goal completion anticipated for March 21, 2025. There was no treatment plan documented in the client record for March 21, 2025, through completion of treatment.
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Plan of Correction
Plan of correction:
Clinical director will conduct weekly audits of active client charts to ensure treatment plan updates are completed and documented on time.
Staff Training: All clinical staff will complete a refresher training on treatment planning standards and documentation expectations by August 5, 2025.
Responsible Staff
Clinical Director: Oversees chart audits and provides direct supervision to counselors.
Counselors: Responsible for completing and documenting treatment plan updates.
Compliance Officer: Monitors compliance trends and reports findings to leadership.
Monitoring and Evaluation
Weekly chart audits will continue for 90 days, with results reviewed in clinical team meetings.
Any missed or late updates will be addressed with corrective action and documented.
After 90 days, audit frequency will be reassessed based on compliance data.
Completion Date
Staff training: August 5, 2025
Audit implementation: August 8, 2025
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709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary, in four of four records reviewed.Client # 1 was admitted February 25, 2025, and discharged March 13, 2025. The client record did not contain documentation of a discharge summary.Client # 2 was admitted on March 9, 2025, and discharged on March 28, 2025. The client record did not contain documentation of a discharge summary.Client # 3 was admitted on February 23, 2025, and discharged on March 28, 2025. The client record did not contain documentation of a discharge summary.Client # 4 was admitted on February 12, 2025, and discharged on February 26, 2025. The client record did not contain documentation of a discharge summary.
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Plan of Correction
EHR Alerts: The Electronic Health Record system will be configured to flag incomplete discharge documentation and prevent chart closure until the summary is uploaded.
Staff Training: All clinical staff will receive training on discharge documentation standards by August 5, 2025.
Responsible Staff
Clinical Director: Oversees discharge documentation and staff compliance.
Compliance Officer: Conducts audits and reports compliance trends.
Monitoring and Evaluation
Weekly audits of discharged client records will be conducted for 90 days.
Audit results will be reviewed in monthly compliance meetings and used to adjust procedures if needed.
Completion Date
EHR alert setup: August 1, 2025
Staff training: August 5, 2025
Audit implementation: August 8, 2025
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