INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 9-10, 2026, 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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705.4 (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 conducted on June 9-10, 2026, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.During the inspection, it was observed that the groups being facilitated could be seen as the rooms had glass doors and panels with no blinds or film. This was in Group Room 107 and Lounge Room 108.
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Plan of Correction
Implementation of this corrective action plan will ensure that resident privacy is consistently protected through appropriate physical safeguards, reinforce compliance with DDAP expectations and HIPAA privacy principles, and establish sustainable monitoring processes that support resident dignity, confidentiality, and a survey-ready environment.
Permanent Corrective Action
The facility will install permanent privacy measures that include:
- Frosted privacy window film
Each installation will maintain adequate natural lighting while preventing unauthorized viewing into protected resident areas.
Areas evaluated include:
- Group counseling rooms
- Individual counseling offices
- Intake and assessment rooms
- Medical examination rooms
- Staff offices containing protected health information
Responsible Person: Facilities Director
Training
All maintenance, environmental services, supervisors, and clinical leadership will receive education regarding:
- Resident privacy requirements
- DDAP standards
- HIPAA privacy expectations
- Resident dignity
- Reporting damaged privacy barriers
- Environmental rounds documentation
Monitoring Plan
The facility will implement ongoing monitoring including:
Weekly
- Facilities inspection of all resident areas
Monthly
- Environment of Care Committee review
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to provide a complete patient record which is to include a discharge summary.Patient # 4 was admitted on February 8, 2026, and was discharged on February 20, 2026. Documentation of a discharge summary was missing from the patient record.
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Plan of Correction
The facility has implemented the following corrective actions:
- Provided training on Continuing Care Planning Policy to clearly define documentation requirements.
- Implemented a standardized Continuing Care Plan template for all levels of care.
- Required discharge planning to begin within the first 24 hours of admission and be updated throughout treatment.
- Implemented a discharge checklist requiring supervisory verification before discharge completion.
- Required Clinical Supervisor to review all discharge records for completeness before record closure.
Monitoring Plan
The Quality Department will:
- Review 100% of all discharges monthly.
- Measure:
- Percentage of discharge summaries completed on time.
- Average completion time.
- Provider-specific compliance rates.
- Corrective actions for overdue records.
- Report findings monthly to:
- Quality Improvement Committee
- Clinical Leadership
- Governing Body
If compliance falls below 95%, an immediate focused corrective action review will be initiated.
Person (s) Responsible
- Clinical Director
- Quality Improvement Director
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to provide a complete patient record which is to include an aftercare plan, in one of two applicable records reviewed.Patient # 1 was admitted to detoxification services on January 27, 2026, and transferred to residential services on February 3, 2026. Patient # 1 successfully completed treatment on February 14, 2026. The Aftercare Plan/Discharge Instructions form dated February 13, 2026, was missing documentation of an aftercare appointment.
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Plan of Correction
The facility has implemented the following corrective actions:
- Provided training on Continuing Care Planning Policy to clearly define documentation requirements.
- Implemented a standardized Continuing Care Plan template for all levels of care.
- Required discharge planning to begin within the first 24 hours of admission and be updated throughout treatment.
- Implemented a discharge checklist requiring supervisory verification before discharge completion.
- Required Clinical Director to review all discharge records for completeness before record closure.
Monitoring Plan
The Quality Department will:
- Review 100% of all discharges monthly.
- Measure:
- Percentage of discharge summaries completed on time.
- Average completion time.
- Provider-specific compliance rates.
- Corrective actions for overdue records.
- Report findings monthly to:
- Quality Improvement Committee
- Clinical Leadership
- Governing Body
If compliance falls below 95%, an immediate focused corrective action review will be initiated.
Person (s) Responsible
- Clinical Director
- Quality Improvement Director
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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 patient records, the facility failed to provide a complete patient record which is to include a discharge summary.Patient # 2 was admitted to detoxification services on March 5, 2026, and transferred to residential services on March 11, 2026. Patient # 2 was discharged on March 20, 2026. Documentation of a discharge summary was missing from the patient record.
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Plan of Correction
The facility has implemented the following corrective actions:
- Provided training on policy and procedure to require completion of all discharge summaries within 7 calendar days of discharge (or a shorter timeframe if required by payer or organizational policy).
- Educated all clinical staff regarding documentation requirements and timelines.
- Implemented a weekly compliance report mandating current status of DC summaries to ensure compliance.
- Assigned Clinical Director responsibility for reviewing documentation completion status weekly.
- Established escalation procedures for documentation exceeding required timeframes.
- Added discharge summary timeliness to Quality Assurance and Performance Improvement (QAPI) monitoring.
To ensure sustained compliance, the organization has implemented:
- Weekly electronic delinquent documentation reports.
- Monthly documentation audits.
- Supervisor sign-off verifying completion.
- Provider performance metrics incorporating documentation timeliness.
- Quarterly documentation compliance reviews by the Quality Department.
- Annual documentation training for all clinical staff.
Person Responsible
- Clinical Director
- Quality Improvement Director
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