INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2023 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 Innova 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #3, who was hired as a counselor on February 27, 2023, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Human Resources Team will verify employees hired as a Counselor have at least 1 year of clinical experience with a bachelor's degree. This will be confirmed prior to onboarding the individual. Otherwise, the employee will be hired as a Counselor Assistant and will follow regulations for that position.
Employee #3 has since reached 1 year of clinical experience. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and wash rooms by exhaust fan or window. The ventilation fans in the bathrooms in bedrooms 185 and 191 were inoperable.
This findings was reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance supervisor went up into the attic to inspect, and he could not find the issue as the vents were open and exhaust fans were operating. A contractor who specializes in HVAC will be coming out to the facility to resolve the issue. We will not house patients in these bedrooms while the fans are out of order. The maintenance supervisor will do monthly checks to ensure ventilations fans in the bathrooms are operating properly. |
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 fire drill logs from August 2022 through July 2023, the facility failed to maintain a written fire drill record including whether the fire alarm or smoke detector was operative.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The template used to document monthly fire drills now includes a section to indicate whether the fire alarms were operative. The individuals who conduct fire drills were made aware of this addition to the form and will complete this section moving forward starting with August 2023 fire drill. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of detoxification client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of two applicable client records.
Client #9 was admitted on June 6, 2023 and discharged on June 8, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Compliance Director communicated to All Staff reminding them to use the 'Administrative Discharge' form in our EMR when a patient is involuntarily discharged from the program. This form has a section for staff to complete explaining the reason for discharge. The patient's signature is required on the form, and patients will be offered a copy of the form upon discharge. |