Why isn't Narconon Being Investigated by the State of Georgia?

Patrick W Desmond died while under the care of Narconon of Georgia died while under the "care" of narconon of georgia. A candlelight vigil for him was held in July.

Candlelight Vigil for ex narconon patient

It probably would not have happened if the State of Georgia DHR Regulatory Agency had been doing it's job, but it wasn't. There were previous violations that appeat to have been shoved under the rug. How did Narconon get away with these violations from the State of Georgia and remain in operation?

Here is what is on record for Sept 2006 and April 2007. Notice the lack of explanation between the first report and the second.

Georgia Department of Human Resources, Office of Regulatory Services State Form
Statement of Deficiencies and Plan of Correction
Inspection begin date 9/12/2006 Inspection end date: 9/13/2006

Name of Provider or Supplier
NARCONON OF GEORGIA
5688 PEACHTREE PARKWAY #B1
NORCROSS, GA 30092

Inspection Results
N 0000 Initial Comments

At the time of the follow-up to the relocation and licensure survey completed May 16, 2006, it was determined that Narconon of Georgia Outpatient Program remains out of compliance with Chapter 290-4-2, Rules and Regulations for Drug Abuse Treatment and Education Programs. Previously cited deficiencies remaining out of compliance were N311, N901, N1003, N1400, N14002, N1405, N1503 and N1504. The following new deficiencies cited were N911, N1008, N1303, N1403 and N1408. N 0311 290-4-2-.03(l) Definitions

In these rules, unless the context otherwise requires, the words and phrases set forth herein shall mean the following: ...

(l) "Outpatient Drug Treatment Program" means a non-residential program staff by professional and paraprofessional persons that provides drug treatment or therapeutic services, primarily counseling and other supportive services for drug dependent persons, and is not classified as an ambulatory detoxification program or
Specialized Day Treatment Program.

This Requirement is not met as evidenced by:

Based on program description, client records, and staff interviews, it was determined that the facility does not meet the definition of an outpatient drug treatment program due to the provision of detoxification services to clients, nor does the facility meet requirements for licensure as a program that includes detoxification due to the facility practice of employing exercise, sauna,
vitamins, minerals and other supplements exceeding the Institute of Medicine recommendations, potentially placing clients' health at risk. Findings were:
The facility submitted an updated application, dated September 13, 2006 for a new license. The program modality request on the application was for outpatient treatment services.

A review of the facility's program description reflected that the facility did not engage in any type of medical detoxification, but further identified that the objective of the program was to assist the client in post-acute withdrawal and rid the body of drug residuals and toxins. The program regimen, in the program description, includes a physical process of withdrawal from toxins and drugs though exercise, sauna, and nutritional supplements. The program description did not specify the amounts of vitamins, minerals, oils, and other supplements, and the extent of the exercise and sauna that were routinely implemented as a part of the purification phase of the detox treatment.

The program used L. Ron Hubbard's "Clear mind-Clear Body" as the protocol for Step 2 of the program, the purification phase. Review of step 2: The Narconon New Life Detoxification Program" directed the program clients though a physical regimen to include: running or walking to increase circulation, monitoring the client's vital signs, using various amounts of liquids, nutrition (in the form of vitamins and supplements) and the sauna to rid the client's body of drug residuals and toxins.
Even though the facility no longer has the sauna located at the facility it continues to prescribe the amount of time the client should stay in the sauna, exercise, and the amount of vitamins, minerals, oils, and other supplements.

Twelve of 12 sampled client records (client #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16) reviewed on 9/12/2006 and 9/13/2006, had no documentary evidence of a physician's order dictating the amount and frequency of chemicals and other supplements prescribed for each client in the purification phase. All 12 sampled records lacked documentary evidence of continued medical oversight to include assessments or laboratory test if required, depending on the clients' changing needs. The client records also revealed that the client files lacked daily
vital signs and exercise times.

The client records also confirmed that the client still discusses the information filled out on the "daily report form" with the facility. The record also revealed that the facility still prescribed vitamins, minerals, oils, and other supplements which far exceeds the Recommended Daily Allowances (RDA).

Review of client admission requirements still indicates that as part of the admission agreement, the clients sign waivers that agree to hold the Narconon program and its affiliates harmless from any and all liability which may arise out of or related to any action of failure to act during the program outlined in the program description. Furthermore, the clients agree to knowingly accept
the risk for any physical, mental, emotional or spiritual damages of any kind that results from participation in the sauna/exercise program and the program's related vitamin and supplement regime that exceed the Institute of Medicine's Recommended Daily Allowances (RDA).

It was determined that the practices of the facility exceed the services allowed in an outpatient drug treatment program, the detoxification program failed to meet accepted standards, and the program description and application failed to accurately designate the ASAM level at which services are provided.
This rule was previously cited on May 16, 2006.

N 0901 290-4-2.09(2) Administration
Program Description. A licensed program shall develop and implement written policies and procedures that describe the range of treatment and services provided by the program and must specify which American Society of Addiction Medicine (ASAM) levels of care will be offered. Such policies and procedures shall describe how identified treatment and services will be provided and how such treatment and services will be assessed and evaluated. A program description must show what services are provided directly by the program and what treatment and services are provided in cooperation with available community or contract resources. The program description shall be reviewed at least annually and updated when treatment or services change.

This Requirement is not met as evidenced by:
Based on a review of the program description, and the program policies and procedures, it was determined the program description did not sufficiently describe the range of treatment and services provided for all clients. The findings were:
The program description specified Narconon of Georgia functioned at an (The American Society of Addiction Medicine) ASAM I level. this level is a outpatient treatment program that does not include a detoxification program. The submitted program description including provided policies and procedures, did not specify the amount of excessive vitamins, minerals, oils, other supplements, and the extent of exercise and sauna time that were routinely implemented as a part of the purification phase of the treatment. The program used L. Ron Hubbard's "Clear Mind-Clear Body" as the protocol for Step 2 of the program, the purification phase.

The facility as of 7/15/2006 no longer does this phase at the facility location, but still does not have the policies and procedures describing the training, qualification and responsibilities of the
staff supervising the purification phase, and how the process would be assessed and evaluated. This rule violation was previously cited on May 16, 2006.

N 0911 290-4-2-.09(7) Administration
A program shall maintain written records for each employee and the administrator. Each individual file shall include:
1. Identifying information such as name, address, telephone number, emergency contact person(s);
2. A ten year employment history or a complete employment history if the person has not worked ten years and at least two reference checks prior to employment;
3. Records of applicable licenses, health requirements, and educational qualifications as required by these rules;
4. Date of employment;
5. The person's job description or statements of the person's duties and responsibilities;
6. Documentation of training and orientation required by these rules;
7. Any records relevant to the employee's performance including at least annual performance evaluations; and
8. For programs serving children, the results of criminal record checks obtained from a law enforcement agency.
This Requirement is not met as evidenced by:
Based on staff interview and record review, it was determined the facility failed to maintain accurate personnel records on the only medical doctor on the staff roster (employee #14).

Findings were:
A list of staff requested from the administrator included one medical doctor. The Narconon of Georgia Organization Chart also referred to the same medical doctor.
No staff record was provided after repeated request for the medical doctor's file from the administrator.
The administrator provided the program's staff schedule and the staff roster that gave a brief synopsis of each staff member. The medical doctor was not on the staff schedule or staff roster from May 2006 through September 2006, even though the same medical doctor is listed on the March 6, 2006 application.

On 9/12/2006 at 2:30 p.m. the administrator was informed of this finding and did not produce any further documentation for the only medical doctor on staff.
N 1003 290-4-2-.10(4) Staffing The medical responsibility for each client will be vested in a licensed physician who oversees all medical services provided by the program. Physician assistants or nurse practioners may be utilized to the extent allowed by state practice acts.
This Requirement is not met as evidenced by:

Based on records review and client and staff interview, it was determined that the facility failed to provide a licensed physician to ensure medical oversight for all client services provided by the program resulting in potential harm for all clients. Findings were:

On day one of the survey, the administrator confirmed at 10:41 a.m. that the sauna was removed from the program, however, client interviews revealed that the facility continued to use L. Ron Hubbard's "Clear Mind-Clear Body" as the protocol for Step 2 of the program purification phase. Review of step 2: The Narconon New Life Detoxification Program" directed the program clients though a physical regimen to include: running or walking to increase circulation, monitoring the client's vital signs, using various amounts of liquids, nutrition (in the form of vitamins and
supplements) and the sauna to rid the client's body of drug residuals and toxins.
Six of six (#8, #16, #17, #18, #19, and #20) client interviews conducted 9/12/2006 and 9/13/2006 reported completing step 2 (sauna):

-#8 admitted 8/1/2006 used the sauna at a person's house;
-#16 admitted 5/28/2006 used the sauna at Narconon;
-#17 readmitted to the program 6/2/2006 used the sauna at a doctor's office;
-#18 admitted 1/23/2006 used the sauna at a doctor's office;
-#19 admitted 7/14/2006 used the sauna at a person's house;
-#20 admitted 5/28/2006 at Narconon; # 20 revealed that they removed the sauna about 2 months
ago (July 2006) and the clients were directed to use the sauna at Ballys, L.A. Fitness, The Church of Scientology, staff members apartment complex and then a person's house. Twelve of twelve sampled client records (#1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16) reviewed on 9/12/2006 and 9/13/2006, had no documentary evidence of continued medical oversight to include assessments or laboratory test if required, depending on the clients'changing needs because of the modality of treatment used in the purification phase.

Even though the facility no longer has the sauna on the premises, the program continues to prescribe the amount of time the client should stay in the sauna, exercise, and the amount of vitamins, minerals, oils, and other supplements.
The client records also confirmed that clients still discuss the information filled out on the "daily report form" with the facility. The records also revealed that the facility staff was still prescribing vitamins, minerals, oils, and other supplements which far exceeds the Recommended Daily Allowances (RDA) with potential risk to the clients.

Review of client admission requirements still indicates that as part of the admission agreement, the clients sign a waiver that agreed to hold the Narconon program and its affiliates harmless from any and all liability which may arise out of or related to any action of failure to act during the program outlined in the program description. Furthermore, the clients agree to knowingly accept the risk for any physical, mental, emotional or spiritual damages of any kind that results from
participation in the sauna/exercise program and the program's related vitamin and supplement regime that exceed the Institute of Medicine's Recommended Daily Allowances (RDA)

When queried on September 13, 2006 at 2:00 p.m., the clinical director of the program confirmed that the documentation was not adequate. When asked for further information, the clinical director did not add any additional information.
This rule violation was previously cited on May 16, 2006.

N 1008 290-4-2-.10(7)(b) Staffing
Additional training consisting of a minimum of thirty (30) clock hours of training or instruction shall be provided annually for each staff member who provides treatment services to clients. Such training shall be in subjects that relate to the employee's assigned duties and responsibilities.

This Requirement is not met as evidenced by:
Based on a review of employee records and staff interview, it was determined that the facility failed to provide 30 hours of training for five of eight sampled employees who worked at the facility for more than a year (employees #1, #3, #5, #11, and #12). The findings were:

Seven of eight personnel records did not have documentation of thirty hours minimum of any treatment related training.
Employee #1 had 18 hours of training.
Employee #3 had 1 hours of training.
Employee #5 had 10 hours of training.
Employee #11 had 4 hours of training.
Employee #12 had 0 hours of training.
During an interview on 9/12/2006 at 2:00 p.m. the administrator was informed of this finding and was unable to confirm that the employees went to training or produce further documentation showing evidence of training on the above mentioned employees' records.

N 1303 290-4-2-.13(1)(b)1. Client Referral, Intake, Assess, Adm
... Physical Assessment. At the time of admission, a preliminary physical assessment shall be done, at a minimum, by a Registered Nurse or Licensed Practical Nurse under the supervision of a RN or physician and shall include documentation of vital signs, appropriate screening tests for STD and TB, urine drug screens, a determination of whether the client requires a physical or psychiatric examination by a physician according to established protocols, and laboratory tests as clinically indicated. Laboratory tests required upon admission for clients in each program modality, in addition to those tests required for all modalities, will be determined by the
programs and documented in their policy and procedures as to the criteria used to determine and specify which minimum lab tests are to be done for each modality. Other lab tests may be required by the physician as clinically indicated. If an examination by a physician is indicated, arrangements shall be made for such an examination as appropriate. The assessment shall also include circumstances leading to admission, mental status, support system, psychiatric and medical history, risk assessment for HIV, history of use of drugs, including the age of onset, duration, patterns, and consequences of use, family history of drug use, route of administration and previous treatment. If a client has been referred for treatment from another facility, the results of a physical examination and laboratory tests from the other facility may be documented and used to assess physical status,
provided that such physical examination was done within six months of admission, and there has been no significant change in the physical status of the client. Further assessments or laboratory tests may be required depending upon the modality of treatment needed or the client's changing condition. ...
This Requirement is not met as evidenced by:

Based on client record review and staff interview, it was determined that the facility failed to do a complete client physical assessment at the time of admission for four of 12 sampled client records (clients #1, #4,#12, and #16)Review of client records on 9/12/2006 and 9/13/2006, revealed :
Four of 12 sampled records (#1, #4, #12, and #16) did not have documentation of a urine drug screen being done at the time of admission. A baseline urine screen test is required to determine specific drug use and to have a guide for measuring improvement or effectiveness, on random future drug screens, in the clients' drug treatment program.

Client # 1's admission date was 5/6/2006 and the urine drug screen test was done on 5/30/2006.
Client # 4's admission date was 7/31/2006 and the urine drug screen test was done on 8/2/2006.
Client #12's admission date was 7/27/2006 and the urine drug screen test was done on 8/4/2006.
Client # 16's admission date was 7/14/2006 and the urine drug screen test was done on
8/24/2006.
When queried on September 13, 2006 at 2:00 p.m., the clinical director of the program confirmed that the documentation was not adequate. No further information was available.

N 1400 290-4-2-.14 Individual Treatment Planning
A program must develop and implement a complete individualized treatment plan for each client. Such treatment plans shall be modified and updated as necessary, depending upon the clients' needs.
This Requirement is not met as evidenced by:
Based on client record review and staff interview, it was determined that the facility failed to develop and implement a complete individualized treatment plan for 12 of 12 sampled clients
(client #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16). Findings were:
Review of client records on 9/12/2006 and 9/13/2006, revealed that all 12 sampled client records did not have individualized treatment plans. All 12 sampled clients had the same three pre-printed objectives written in their treatment plans. The objectives were:
1. Regular attendance at Narconon of Georgia.
2. Provide negative drug screens.
3. Participate in training routines.
During an interview on September 13, 2006 at 3:00 p.m., the administrator was informed of this finding and admitted the facility did not individualize client treatment plans.
This rule violation was previously cited on May 16, 2006.
N 1402 290-4-2-.14(b) Individual Treatment Planning Complete Treatment Plan. The complete treatment plan must be comprehensive, formulated by a multi-disciplinary team with the input of the client, approved by the clinical director, completed within thirty days from admission, and shall contain sufficient information about the client's expected treatment[.]...
This Requirement is not met as evidenced by:
Based on client record review and staff interview, it was determined that the facility failed to develop a complete treatment plan which was approved by the clinical director for nine of 12 sampled clients (clients #1, #3, #4, #6, #12, #13, #14, #15, and #16). Findings were:
Review of client records on 9/12/2006 and 9/13/2006, revealed that nine of 12 sampled clients'records did not contained documentation showing evidence that the clinical director approved the treatment plan.

During an interview on September 13, 2006 at 4;30 p.m., the administrator was informed of this finding and was unable to produce documentation showing evidence that the clinical director approved the treatment plan.

This rule violation was previously cited on May 16, 2006.N 1403 290-4-2-.14(b)1. Individual Treatment Planning Complete Treatment Plan. The complete treatment plan [shall include]: ...
1. Descriptions of the client's problems and needs; ...
This Requirement is not met as evidenced by:
Based on client record review and staff interview, it was determined that the facility failed to develop a complete treatment plan which includes a description of the clients' problems and needs for 12 of 12 sampled clients (client #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16).

Findings were:
Review of client records on 9/12/2006 and 9/13/2006, revealed that all 12 sampled clients' records contained the list of abused drugs (example: methadone, cocaine, etc.) and did not contain the descriptions of the clients' problems.
During an interview on September 13, 2006 at 4:30 p.m., the administrator was informed of this finding and was unable to produce documentation showing the clients' problems and needs in the clients' treatment plans.
N 1405 290-4-2-.14(b)3. Individual Treatment Planning
Complete Treatment Plan. The complete treatment plan [shall include]: ...
3. The interventions and services that the program will provide to help the client achieve the individual goals and
desired outcomes; ...
This Requirement is not met as evidenced by:
Based on client record reviews and staff interview, it was determined that the facility failed to develop treatment plans which state the interventions and services the program will provide to help the clients achieve the individual goals and desired outcomes, for 12 of 12 sampled clients(clients #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16). Findings were:

Review of client records on 9/12/2006 and 9/13/2006, revealed that all 12 sampled clients did not have treatment plans which stated the interventions and services the program will provide to help the client achieve the individual goals and desired outcomes. The clients had interventions like "client will sign in/out at Narconon of Georgia one time daily for 60 days."

During an interview on September 13, 2006 at 4:00 p.m., the administrator was informed of this finding and confirmed that the treatment plans did not state the interventions and services the program will provide to help the client achieve their goals. This rule violation was previously cited on May 16, 2006.

N 1408 290-4-2-.14(c) Individual Treatment Planning
Progress Notes. A program shall document the services received by the client and document chronologically observations of the client's clinical course of treatment which includes the client's response to treatment and progress towards achieving individual goals and desired outcomes. Progress notes shall be documented by the
staff members assigned primary responsibility for the client's care, and shall be legible and recorded in the client's plan. Progress notes shall be recorded as applicable;

1. at the end of each shift in the client's medical record for residential detoxification programs; or
2. following any contact with a client undergoing ambulatory detoxification or narcotic treatment; or
3. at least weekly for substance abuse treatment residences; or
4. daily for day treatment programs; or
5. whenever there are face-to-face contacts with the client for outpatient drug treatment programs; or
6. whenever the client is observed to engage in a behavior which may effect a change in the treatment plan.
This Requirement is not met as evidenced by:
Based on client record review and staff interview, it was determined that the facility failed to
document the services received by the client in progress notes for 12 of 12 sampled clients
(client #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16). Findings were:
Review of client records on 9/12/2006 and 9/13/2006 revealed, that the notes in the clients'records did not document, chronologically, observations of the clients' clinical course of treatment which included the clients' response to treatment and progress towards achieving individual goals and desired outcomes.
Interview with the administrator on 9/12/2006 at 2:30 p.m. confirmed that the progress notes were incomplete.

N 1503 290-4-2-.15(c) Medications
Medications. ... Such policies and procedures shall include the following:
(c) Unless self-administered, all medications are administered by a physician, physician's assistant, or nurse. ...
This Requirement is not met as evidenced by:
Based on review of client and employee records, and a statement overheard, it was determined that the facility failed to have medication administered by a nurse for 12of 12 sampled clients
(client #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16). Findings were:
Review of client records on 9/12/2006 and 9/13/2006, revealed that the clients' records did not have any documentation that the vitamins and minerals were dispensed by a nurse. The clients'daily report forms and interviews with clients revealed that the clients are being given vitamins and minerals as a part of their daily regimens. At least one of the twelve sampled clients stated that he/she was on medication prescribed by a physician.

On 9/12/2006 at 2:00 p.m. the surveyor overheard that the staff needed the key to the safe so they could get a clients' medications. There was no nurse at the facility to dispense medications on 9/12/06.
This rule violation was previously cited on May 16, 2006.
N 1504 290-4-2-.15(d) Medications
Medications. ... Such policies and procedures shall include the following: ...
(d) Any medications prescribed, administered or self-administered under supervision are documented on an individual medication administration record that is filed with the individual treatment plan, unless maintained as a clinical record at the client's bedside or in the medication room in a residential detoxification setting. The record must include:
1. Name of medication;
2. Date prescribed;
3. Dosage;
4. Frequency;
5. Route of administration;
6. Date and time administered; and
7. Documentation of staff administering medication or supervising self-administration. ...
This Requirement is not met as evidenced by:
Based on review of client records, it was determined that the facility failed to document and maintain prescribed medication as a clinical part of the client records for 12 of 12 sampled clients (client #1, #2, #3, #4, #5, #6, #8, #12, #13, #14, #15, and #16). Findings were:
Review of 12 of 12 sampled clients, participating in the sauna/exercise program, revealed that the clients did not have documentation of prescribed medication as part of their clinical records.
This rule violation was previously cited on May 16, 2006.
Page 14 of 14


TO THIS:

Inspection Results
As of: Wednesday, July 30, 2008

Georgia Department of Human Resources,
Office of Regulatory Services State Form
Statement of Deficiencies
and Plan of Correction
Inspection begin date
Inspection end date:
4/24/2007
4/25/2007
Name of Provider or Supplier
NARCONON OF GEORGIA
Street Address, City, State Zip Code
5688 PEACHTREE PARKWAY #B1
NORCROSS, GA 30092

N 0000 Initial Comments
At the time of the licensure survey, it was determined that Narconon of Georgia, was in substantial compliance with Chapter 290-4-2, Rules and Regulations for Drug Abuse Treatment and Education Programs. The following deficiencies were cited.
N 1500 290-4-2-.15 Medications If a program administers medications, written policies and procedures for prescriptions, administration andsecurity of medications shall be established and implemented. This Requirement is not met as evidenced by:

Based on facility policy review and staff interview, it was determined that the facility failed to establish written policies and procedures for the administration and security of medications administered as part of the detoxification program.

Findings were:
Review of facility policy and procedures revealed no documented evidence of written policies and procedures for the administration and security of medications (vitamins and minerals)administered during the detoxification program.
Interview on 4/25/2007 at 9:30 a.m. with the facility executive director confirmed that the facility did not have established policies and procedures for the administration and security of medications.
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