INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 14, 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on August 14, 2025, the facility failed to keep the grounds clean, safe, sanitary and in good repair at all times.
Ceiling tiles were observed to be discolored and bulging in the food storage area.
A ceiling tile was observed to be missing from one occupied office, a bucket with water under this area, and a mold-like substance was observed on the ceiling.
Multiple ceiling tiles were observed to be missing from one unoccupied office, a mold-like substance was observed on the ceiling, and strips of vinyl plank flooring was missing.
A hole was observed in the wall of the conference room.
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Plan of Correction
Updated: Mold like substance- The offices have been treated for mold. This was completed on 9.10.2025 per the executive director. Ceiling Tiles/Flooring- The executive director has hired a contractor to fix the ceiling tiles and leak issues. The facilities manager is currently exploring quotes and consultation to either fix or replace the floor. Ceiling- This will be completed on or before 9/15/2025. Flooring/ hole in conference room- This will be completed on or before 9/19/2025.
The facilities manager will be responsible for ensuring the office is good and functioning condition. For all maintenance issues it will be addressed immediately by following these steps:
1. Report the issue by completing a maintenance ticket within our online incident reporting system- Safety Culture.
1A. Report will notify the executive director and compliance director via email alerts once report is submitted.
2. Upon notification, the executive
director will secure quotes to get the issue fixed and the compliance will ensure the issues has been fixed by scheduling a site visit either in person or virtual.
3. Compliance director will close the maintenance ticket in Safety culture.
4. Monthly maintenance logs will be reviewed and revised. In addition these will be completed monthly by the facilities manager or designed staff. Documentation will be completed and filed in location easily accessible to the compliance director.
4. Compliance director will complete in person visits at least quarterly.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection conducted on August 14, 2025, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers.
Garbage bags were observed on the ground, in the parking lot, outside the covered garbage container and outside the laundry room door.
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Plan of Correction
Update: On 8/17/25 the trash was removed.
We have identified the trash collection needed to be increased to fit the needs of the organization. We have increased our collection schedule to twice a week. It will be the responsibility of the executive director to ensure the plan is implemented and relevant to the needs of the organization. Adjustment will made as required. |
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 on August 14, 2025, the facility failed to have hot water under pressure. Two unisex bathrooms were observed to not have hot water come out of the bathroom sink when the hot water spigots were turned on.
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Plan of Correction
The executive director and facility manager is currently exploring plumbing quotes to have the issue resolved by 9/30/25.
The facilities manager is responsible for checking the water pressure, temperature, and functioning during monthly documented maintenance checks.
Documentation will be verified monthly by the compliance director.
Incident reporting policy will be updated to include the use of maintenance tickets, monthly reporting, quarterly compliance site visits, and monthly documentation requirements. |