INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2025 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of training documentation, the facility failed to complete an assessment of staff training needs.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Innovo Detox's Executive Director will be responsible for conducting an annual assessment of staff training needs through the collection and analysis of personnel training surveys, performance evaluations, and supervisory feedback. The data will be reviewed and discussed during the annual Workforce Development Meeting to identify trends, gaps, and emerging training priorities. A written analysis report summarizing findings and recommended actions will be completed by the Executive Director during Quarter 3 of each fiscal year and incorporated into the facility's annual staff development plan. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of training documentation, the facility failed to complete an overall plan for addressing training needs.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Innovo Detox has developed (final review scheduled for 10.31.25) and will implement January 2026, a comprehensive Staff Training and Development Plan designed to meet the requirements of 28 Pa. Code §704.11. The plan ensures that all personnel receive appropriate orientation and ongoing training based on their assigned duties and level of responsibility. Training content includes, but is not limited to, confidentiality, client rights, emergency procedures, infection control, and other job-related competencies essential to quality behavioral health care. The program aligns with the standards of the applicable state regulations to promote consistent, ethical, and effective service delivery. Training needs are assessed annually by the Executive Director, Compliance and Human Resources Departments through staff feedback, performance evaluations, and incident reviews. All training activities are documented in employee records, monitored for completion, and reviewed quarterly by leadership (Executive Director, Compliance, and HR) to ensure ongoing compliance and continuous quality improvement. This process ensures that staff remain knowledgeable, competent, and equipped to uphold client safety and regulatory standards in accordance with state regulations. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of training documentation, the facility failed to complete an annual evaluation of the overall training plan.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A written analysis report summarizing the findings and recommended actions from staff training and development activities will be completed by the Executive Director during Quarter 3 of each fiscal year. This report will include an evaluation of the facility's training effectiveness, identification of ongoing training needs, the plan itself, and recommendations for improvement. The findings and recommendations will be incorporated into the facility's Annual Staff Development Plan to ensure continuous compliance, performance improvement, and alignment with regulatory requirements. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of training documentation, the facility failed to develop an annual individual training plan in seven out of seven files reviewed.
Staff #1 was promoted to Program Director on March 3, 2025.
Staff #2 was promoted to Facility Director on August 11, 2025.
Staff #3 was promoted to Clinical Supervisor on August 27, 2025.
Staff #4 was hired on April 21, 2025.
Staff #5 was hired on February 25, 2025.
Staff #6 was hired on May 12, 2025.
Staff #7 was hired on March 31, 2025.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Innovo Detox ensures that each staff member has an individualized training plan developed in collaboration with their supervisor. As part of ongoing individual supervision, the supervisor and supervisee identify training and development needs based on the employee's prior education, professional experience, current job functions, and demonstrated job performance. These individualized plans are created at the time of hire and reviewed at least annually, or more frequently as performance needs or role changes are identified. This process ensures that all staff receive targeted, competency-based training that supports their professional growth, enhances service quality, and maintains compliance with applicable state, federal, and accreditation standards. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on discussions with facility staff, the facility failed to obtain the services of a certified public accountant for an annual financial audit.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Innovo Detox will ensure that its fiscal management practices include an annual independent financial review conducted by a certified public accountant (CPA). The facility's Chief Financial Officer (CFO) is responsible for coordinating and overseeing this process to ensure accuracy, transparency, and adherence to generally accepted accounting principles (GAAP). The annual financial review will be completed during the third quarter of each fiscal year and will provide an objective evaluation of the organization's financial operations, supporting accountability, fiscal integrity, and compliance with state regulatory requirements. |