DCH-GA-2012-10-29-Pur-O-Cleanse-MiscDocs_ocr

.. GEO:RGIA.D~....-r<>F Co'MMUN:rn~a

STATE OF GEORGIA

DRUG ABUSE TREATMENT AND EDUCATION PROGRAM PERMIT This is to certify that a permit is hereby granted to

NARCONON OF GEORGIA, INC (Name of Governing Body)

to maintain and operate a DRUG ABUSE TREATMENT AND EDUCATION PROGRAM with 0 branch offices, named as -----NARCONON NEW LIFE AMBULATORY DETOXIFICATION

(Name of Faet1ity)

Approval is granted to provide the following programs: OUTPATIENT AMBULATORY DETOXIFICATION PROGRAM

Said facility and premises are located at

in -----=D':::O:,;RA-=-;Vo,lo=L:c:L=E'----- , County of (City or Town}

This permit is effective

ASAM Levels:

11-D

6487 PEACHTREE INDUSTRIAL BLVD SUITE C & D (Street)

DEKALB ___ _;_:..::...:;--'----,Georgia.

September 28, 2012 and remains in effect unless revoked or suspended.

''This permit is granted pursuant to the authority vested in the Department of community Health, Official Code of Georgia, Title 26, Chapter 5, and signifies that the provider complies with the Rules and Regulations of the Department of Community Health on the date this license was issued."

THIS PERMIT IS NOT TRANSFERABLE Permit No: 044-106-D

GEORGIA DEPARTMENT OF COMMUNITY HEALTH HEALTHCARE FACILITY REGULATION OMSION

~DJEI>:.~OF ~hl-:t:nr H'E'L't':'r'S'

STATE" OF GEOR.GIA

DRUG ABUSE TREATMENT AND EDUCATION PROGRAM PERMIT Th[s is to.certifythat a permit is hereby granted to

MAA'FIN D. CO! !EI<t' . 1 (Name of Govetruns Body)

to maintain and operate a

(NameofFacilil>') . ftt:?J77.1r/Je.I'J T Approval is granted to proVide the following programs: RES[9EN'f!Al: -r:REA™FNX PROGRAM ' · /'1{_ /1 - I ·, 17} CJ/

Said faolfrt:y and premises are located at

in ------~D=O~RA~~~IL7L=F~-----'Co {C«y oc-TQwn)

This permit i~ e ·ve

I

\ /

9487 PEA'is;HTREF INDUSTRIAL BLVD SUITE C & D (Sin>et}

___ D=E:..:KAL==B=--"<:-- , Georgia

..-- M<ey er, 20 12---.., and remains In effeCt unLess revoked or suspehded.

"'This permit is granted pursuant the authOrity vested jn the Department of Commun · Health1 Official Code of Georgi~ Title 2Gt Chapter 5, and -signffies that the provider co 1es with the RL:des and Regulations of the Department of CommonrtyHea..tth on the date this ficensewas 'issued ....

THtSPERMIT NOTTRANSFE~LE - - PermitNo:~ 044--106--D . .

HEALTHCARE FACILITY REGUlATION DIVISION SPECIALIZED CARE SECTION 2 PEACHTRE:E STREET N. W.

SUIIE 31.447 ATlANIA, GA 30303-3142

IIEALTIICARE FAC!LlTY REGIJLAT!ON

OCT 2 6 2012

AlECm'm APPLICATION !'OR A LICENSE TO OPEI'IATE A DRUG ABUSI' TREATMeNT AND l'DUCA1'10N PROGRAM

Pl,l!liuant to provis.ion of O.C.Ci.A.26·5·1 at seq. Application Is hereby made to operata the Drug Abuse Tre"Biment and fdvcatlon Program which is identified as follows (Qeparate application raqulrc.d ful' each program location subject to lk:ensure): ~Effective August 3, 2010, a feo must blif paid to; w1Ch new application, change of awnetshlp, chaiJnlif of loccdion, or ronewal of license. Befofo you apply fpr any naw appllc:ation or changes, please dawnlor:Jd the payment coupon and submit the correat p;;wment to the ,ifallbox on ths coupon fDtm. then, please follow thQ directions fat thu app/Jcat;on below.

Section A. Jdontlflcation

Type of Applioallon: lnilial Renewal Update/Change of status(expl•in): X Change status of Narconon

New Life Ambulatory Detoxification from branch to full 7 day a week operation with its own licence

Parent: Su~·units (#) Branches (#)

Type;

(sep, applications required· atlach)

Acoredilation $talus: (optional) IOxplratlon dale

Narconon New life Ambulatory Detoxification Program 678-580-4922 N~me of Program Phone

6487 Peachtree industrial Blvd. Suite 0 and D Doraville Dekalb 30360 Progrnm Streat Address (where services provided) City County Zip coda

Lisl•ddrasses of all residen«al sitos, Including apartment numbers

5688 Peachtree Parkway Norcross GA 30092 [email protected]

Pro~tarn Mailing Addre••

Narconon of Georgia Inc. Official Name of Gov$rnlng Body

Mary Rieser Robin Muse lPC Admlnlsl!<ltor (appointed by Governing Body) Clinical Director

Section a. Ownorshlp Information- Type Qf Ownorohip

Non·Profll

J;:-mail Address

Aaron Anderson

Proprietary F=lroflt

Individual

Partnership

State

___ County

___ City

Community Se!Vice Board

___ Church

___ Corporation (Include copy of certificate of incorporation)

___ Hospilal Authority

_ _:,:X,__ Other (specify) 501(c) 3 Non·Proflt

___ Corporation

---"X"- Olhor (specify)

List narnea and addresses of al! OWI"'ers above with five percent (5%) or more Interest, or officers of a oorparation ot partn.ers of a partnership, ~s applicable (attach additional sheets~ necessary)

Not applicable ---Non Profit

Section C. Programs Modalllles Provided (check alllocatod at program address section A)

Oulpalienl Arnb. Detox X

Intensive (#)

Speciail~od Day Treatment

Dot ox Residertlial Beds: Transilional (#)

Subunit Branch (part tlma, a part of a fUII-Ume liceneed prosram)

Parent name and Jicen5e #

Populations served: male X

adUlt __ X __

Special Program (explain}

X

adole!iicent

(required for subunits and branches)

Maternity (approx #)

children

w food seNice

aga range

Soctlon C. (continued}- ASAM Patlont Placornent Orlt~tla

Outpatient servloos

1!. 1 Jntanslve outpatient

11.5 (circle ono) P~rtlal hospltallzatlon

Specialized Day 'rraatmant and Outpatient

II·D Ambu1at01y detox w/ extended on-site monitoring

Ill. 1 {c.!rcla on0) Clinically-managed low intensity residential

Residential Traneitiona!

Section D. P~;~R;ic;Jnnel (assigned to program addro~:~s: socUon A)

Counselor I Therapis:t I Social Worker (certified or licensed)

Coun5elor (not certified or licensed)

Consultants (specify type)

Registered Nt.~rses

X

111·2·D (clrc!e one)

Ill.~ (circ!o ont))

111.5 (Oh'¢]e ona)

NA

Clinically-managed residential detox

Resldenfii!l Subacute

Ambulatory Oetox

Clinica!lywmanagf;)d medium intensity residel'ltial

Residentiallnlenslty

Clinically-rnan~Qed medlhigh intensity residential

Residential Intensity

# part-tirno

1 2

3

total hrolwk

5 & 24 Hours on call 35

35

Licensed Practical NUI'$$S None now. Will use <IS PRN if qUalified ----

Administrative;~ }=lt;~rsonnel 1 25

M~dlcal Director (name)

Other (specify)

Dr. l..ocarnini Available for appointment1 0 arn-5 pm Mon·Sat. 24 hour on call

Section p, ~ersonnal (a.liilslgnetl to program addrv$s soction A)

Numb~Sr of hours each waak that Drua Treatment & Education Services are scheduled:

Hours each week that a phy5ician, physician's assistant or nurse scheduled to be present:

Speelfle days/hours of operation for the provision of Drug Treatment & Eiduoation:

Minimum number of program staff present during operating hours:

Current number of active Drug Tra~tmGnt &. Education Clients:

Services other than Drug Treatment & Cduca,ion providad at this location:

Section. F. Required Attachmonts.

Comprehanslv~ Program OuUine (include ASAM levells included at this location)

Proof of compliance with laws for tM handling and dispensing ol drugs

Proof of compliance with applicable st~t• & local health, safety, sanitation, building & zoning codes

Affidavit of Lawful Presence In United States

Soction G: OortlflciitiOrt

42

35

7 days a week 9 am-3 pm

two 16

none

f certify that thl$ facility will comply with the Rules and Regulations for Drug Treatment & Eduea.tlon Programs, I understand that a 'license is nonytransferab!e and must be returne the Healthcare ty Regulation Olvlsion if a program close~;, changes location or governing body.

s t }l<l,tO)jl<> b t y kn ledge .

....-pr t. ~- '--- __ty-...._.._ c]o s =-'(... ~ 2-- 1

FOR STATE USE ONLY

Date Raceived:

ApprOved as:

Section I Unit Dirf;lotor Approval I Comments;

Revlewad by;

Effective Dates:

Date of Signature I

'il"'<+il.D F. .,._.l.fNc-e, e:v0"c c.-.... Title

~.-'

" .

f'

HEALrH CARE FACILITY REGULATION SPECIALIZED CARE SECTION 2 PEACHTREE STREET N.W.

SUITE 31.447 ATLANTA, GA 30303~3142

APPLICATION FORA LICeNSE TO OPERATE A DRUG ABUSE TREATMENT AND EDUCATION PROGRAM Pursuant to provision of O.C.G.A.26-t.J-1 ef· &aq. Applloatlon Is hereby made to operate the DrlllJ Abuse lrea\ment and Education Pmgram whloh Is fdent!fled as folrows (separale application raqt!lrad ror enoh program l(lcaUon subjecl to llormaure): *Effecffvo August 3, 20101 a foo mu:~t bfJ pnld for each new appJiGallon1 cllrm{la ~f ownarsfllp, cllange of loaatlon, ot r&n9wal of 1/censo. Before~rr apPlY for any new app/lcaUon or cllangos, pf~aso dawnlottd (he payment coupon and submit tht'l (:Oftect pa:yme to tlla JJiallbox on the coupon form, Then1 pfu(ls~ (OJ/i>W the directions far il1e applloation below. SecUon A fdentJiloallon

Type of Application: Initial.' Renewal__ Update/Change or status(oxplaln):.___x change status

of Narconon New Life Ambulatory Detoxification from branch to full ,7 day a week

operation with Its own license.

Parenl•--~ Sub-units (#) __ aranohes{#}, __ __!(sep. applications raqulred ... afltwh)

Aocredltatlon status: (optional) expiration dale !ype:~"------------

N,...,a::_rc,.,o"'n"'o-"n"'N"'e"-w'"L..,..,if"'e"'A"'m"'b~n.,I.,a.,to"'ry"-"'D"'e""to""x"'lfi"'IC"'n""ti,o"'n_,P'-'l'_,O,.gl,_,'R"'ll"-l--(j78 580 4922 Name of Pro {.I ram

6487 Peachtree Industrial Blvd, Suite C and D Doraville Program Slree! Address (where- services provided) City

6487 Peachtree Industrial Blvd. Suite C and D Doraville

Phoh6

Del<alb County

Del<alb

30360

Zip Code

30360

Program Mailing Address E-mail Address Newllfedetox@narcoi\Onga.org

Official Nama of Governing Body

Maw Rieser Narconon of Georgia Inc,

Robin Muse LPC Admlnlefretor (appointed by Governing Body) Clinical Director

SeoUon B. ownerl3hlp Information-Type of Ownera.hlp

Proprlofary Prom NonProfll

__Jndlvtdua.t _Slate

__partnarshlp _county

__ corporation (Include CQPY of cartlflcate _Cily

offnoorporatlon) _Hos)JIIa! Aulhorlty

__x_Oihe•·(ap•olfy) ·501 (c) 3 r,<ron-pl'Dfit

Aal'O!I Ande•·sou OrHle Manager

__ community S&!VIca Board __ Church

__ Corpcmdlou

____){__.Other {specifY)

Ua.t names and mfdrosaes of o.ll owners above wllh flvo po_roonl (0%} or more Interest, or Qftlootil: of a cooper!'ltlon o.r partners of a

parinarnhlp, as applloable (altaoO additional sheets If htlOt:tssaty):

Not applicable- non-profit

S~otlon C. Program Modalllle.s Provided (chec!( all located at program ciddrass section A)

Outpatlenl_____..Amb. Oatox~ x__speofallzad Day !J'reatmenL_

ResidenUal Beds: Translllonal (fl} __ lntenslve (#} __ Oatox............._w/food setvloa __ _

Subun._ __ l:lranch (part-time, a p;;ut of a !U!Hime licensed prog.) __ _

Parent name. &license#,_ __________ ~-------~---

(rt~qulred for subunlls and branohes)

Populations served: male_x______femata______x__maternlly{apprax. #) __ _

aduiLX...._adole.soanL.--ohlldren__.age range 18- 66

Spsolsf Program(expfaln):~------_c-----------------~-

Section 0. Personnel (assigned to program address seotlon A):

Counselor fTharap\sl/ Social Worker {cerllfled or Ucensed}

Coummlor (hOt lloonsod or oertltfed)

Consultants (apeolfY type)

Ra-91s!ered Nutoee

#full-llrna

NA

#patNime fatal hte/Wk

1 6 & 24 hours on call

2 35

3 35 Lloensed PraoUoal Nurses Nona now. W/lll!&o as P~N If qualified.

1 25 full time oversight

Adm!nlslr!!-Uve Personnel

Program Dlreotor

Medlosl Olreotor(name)

Olher (speoUy)

Dr, Locnt'ninl Available for appointment 1 Oam·5ptn Mon·Sat. 24 hom· on call

Section E. Program Information for services provided at thla location:

Number of hours each Weal< that Drug Treatment & EdlloaUon SeiVIoaa are scheduled: 42

Hours eaoh week thal a tJhYslolan, Physician's assistant or nurtl." schodulod to be. present; 35

Spec!Rc days/hours of operation for tho provision of Drug Treatment & Eduoallon: seven day$ a week sam·- 3 pm

Minimum numbarof!'ragraM staff present durlf'(l opernth"l({hours: two Current nuMbtlr of aotiV~ Drug Trea!me11t & EdUoallon.c)lenta: 16 Satvlooa other than Drug Treatment & Eduoatton provlded at lhislocallon: NONE

Section f. Raqulrel:l Attachments par O.C.G.A. Seotlon 26-5·6:

Comprehensive Program ouurne (tnclode ASAM level/a provlded at lhla looelfon).

Proof of oompllanoa wllh laws for the handling and dlsponsfng of drugs.

Proof of cDmpllance wllh appl/oabla stata & !ooal haatlh, safely, sanitation, building & zoning codes.

Secf~n G. Gerffllcaffon:

I certify !hal this faollity wl!l aotnply will the Rules and Regulattona for Drug Abual} Treatment and EducaUon Programs.

I understand that a Jtoansa Is non~ttansforab\e and must be returned to Heatlhcaro Faollity Regutallon If a program

~ I cart!~ lh~llha above lnfo}nlnllon Is lrua lo the best of my knoWledge.

Et.e ( iJ fi (A.iL Printed Nam't9f- rlncJpa.l Otftcar of Govarn\ng Body of AUthorized Reptesentallva TIUa

FOR STATE USE ONLY

Data Recetved·~~-----------R:avlewed by: _______________ _

Approved aa:_· ~~~~~---~~~--Effecllve dates:'---~~~---~~-~--

Seotton/Unlt Director ApprovaVComments: _____ ~------------------

02/06

-·

State of GA Healthcare Facilitv Reaulation Division

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER:

044-106·0

(X2) MULTIPLE CONsmiJCTION

A. BUILDING · B.~NG ________________ __

STREET ADDRESS, CITY, STATE, ZIP CODE

NARCONON NEW LIFE AMBULATORY DETOX 6487 PEACHTREE iNDUSTRIAL BLVD SUITE C & 0 DORAVILLE, GA 30360 ·

PRINTED: 09/08/2012 FORM APPROVED

(X3) DATE SURVEY COMPLETED

08/2912012

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

ID. PREFIX

TAG

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE

GROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X6) COMPLETE

DATE.

N 000 Initial Comments

At the time of the survey, Narconon New Life Ambulatory Detoxification Program was not In compliance with Chapter 290-4-2, Rules and Regulations for Drug Abuse Treatment and

· Education Programs, as a result of an nltlal survey. The following deficiencies were cited:

N1000 290-4-2-.10(1) Staffing SS=D

Staffing. The program shall have sufficient types and numbers of staff as required by these rules to provide the treatment and services offered to clients and outlined In Its program description.

This Rule is not met as evidenced by: Based on review of the facility policy and procedure, staff recdrd, and staff Interview, It was determined that the facility failed to have the sufficient type of staff to provide the treatment and services outlined by the program for 15 of 15 clients (clients #1-#15), enrolled in the program. Findings were:

A review ofthe facility's policy and procedure/job description for Sauna Exercise In Charge (Sauna I C), revealed that the facility's Sauna IC must be · a Certified Addition Counselor (CAC), or must be actively working towards obtaining certification as aCAC.

A review of the Sauna IC's personnel record (staff # 2) revealed no documentation that he/she was a CAC, or was working towards obtaining certification as a CAC.

An Interview with the facility's Executive Director and the.sauna ICon 8/28/2012 at 3:00p.m., confirmed that the Sauna IC was not actively working towards becoming a Cf\C. The Executive

State of GA lnspecUon Report

NDOO

N1DOO

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLieR REPRESENTATIVE'S SIGNATURE

STATE FORM '"' G3D711

TITLE (X6} DATE

If contfnuat!on sheet 1 of 8

State olGA Healthcare Facility R€lQUiatlon Division

STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION

(X1) PROVIDERISUPPLIERICLIA IDENTIFICATI<:lN NUMBER:

044·106-D

(X2) MULTIPLE CONSTRUCTION

ABUILDING B. WING ________ _



08/29/2012 NAME OF PROVIDER'OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NARCONON NEW LIFE AMBULATORY DETOX 6487 PEACHTREE INDUSTRIAL BLVD SUITE C & D DORAVILLE, GA 30360

(X4)1D PREFIX

TAG

SUMf.IARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE .PRECEDED BY FULL

REGUlATORY OR LSC IDENTIFYING INFORMATION)

N1 ooo Continued From page 1

Director stated, " He/She is going to assist the Sauna IC with enrollment into a local bridge program to complete certification."

N1007 290·4-2·.10(8) Staffing SS=D

Staff Training and Orlentatio'n. Prior to working with clients, all staff who provide treatment and services shall be oriented In accordance with these rules and shall thereafter receive additional training In accordance with these rules.

This Rule is not met as evidenced by: Based on a review of the facility's orientation policy and procedure, employee record reviews and staff Interviews, it was det<irmlned that the

. facility failed to provide staff training and orientation to one of one s11mpled nurse (#4), prior to his/her-working with clients. Findings were:

A review of the facility's policy and procedure; 14R-Orientatlan of Staff, revealed that all staff shall .receive a complete orientation for his/her duties, to Include providing treatment and services, prior to working with clients.

A review of employee·record # 4 on 8/28/2012, revealed no documentation that he/she complete orientation. The employee's record did not Include documentary evidence that the employee rE)celved training that Included caring for clients receiving ambulatory detoxification services.

The Executive Director on·B/28/2012 at 3;15 p.m., stated th<tt employee (#4), was an agency nurse assigned for the day and did not receive orientation or training prior to-working with clients.

ID PREFIX

TAG

N1000

N1007

PROVIDER'S PlAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE

' CROSS-REFERENCED TO THE APPROPRIATE . DEFICIENCY)

(X5) COMPLETE

DAT11

.,

State of GA lnspeollon Report STATE FORM G30711 If continuation sheet 2 of 8

State of GA Healthcare Facllltv Reaulatiori Division

PRINTED:.09/06/2012 FORM APPROVED


(XI) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

A. BUILDING

044-106-D B. WING

08/29/2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE


(X4)1D PREFIX

TAG

SUMMARY STATEMENT OF DgfiCIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FUlL

REGULATORY OR LSG IDENTIFYING INFORMATION)

ID PREFIX

TAG

N1304 Continued From page 2 N1304

N1304 290-4-2-.13(1)(b)2. Client Referral, Intake, N1304 ss~o Assess, ·Adm

... Psycho-social assessment At the time of admission or as soon as. clinically appropriate (but no longer than ten working days), a comprehensive psycho-social assessment shall be done and shall document personal and social history, including current relationships, educational status, living arrangements, social habits, employment status, legal status and related areas ....

This Rule is not met as evidenced by: Based on a revlaw of policy and procedure, client records, employee record, and staff Interview, It was determined that the facility failed to ensure· that a comprehensive psycho-social assessment for four of four sampled clients (#1-#4), was completed by the Clinical Director within ten working days of the clients' admission to the program. Findings were:

A review of the facility policy and procedure ED 33 Admission, Orientation, and Treatment Planning 8/28/2012, revealed that the Clinical Director should complet<;~ the psychosocial · assessments on new client admissions to ensure adequate treatment planning.

A review of client records on 8/28/2012, revealed that all four sampled clients (#1- 114) did not have documentation that a psycho-social assessment was completed by the Clinical Director. The psycho-social assessments were completed and electronically signed by the Executive Director of the program.

A review of the Executive Dlrecto~s personnel records on 8128/2012, revealed no documented


CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

IX5) . COMPLETE

DATE

State of GA lnspecUon Report STATE FORM G3D711 If continuation sheet 3 of 8

State of GA Healthcare Facility R<mulatlon Division

S"fA "fEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDERJSUPPLIERICLIA IDENTIFICATION NUMBER:

044·106-D


A. BUILDING

B. WING·---------



08/29/2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, SOA"fE, ZIP CODE

NARCONON NEW LIFE AMBULATORY DETOX 6487 PEACHTREE INDUSTRIAL BLVD SUITI2 C & D DORAVILLE, GA 30360

(X4) ID PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES. (EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFO!<MATION)

N1304 Continued From page 3

evidence that he/she was qualified to conduct psycho-social assessments. He/She was not a licensed physician, registered nurse or social worker and was not a certified addiction counselor. ·

An interview on 8/28/2012 at 3:30p.m., with the Executive Director, confirmed that he/she was not qualified to conduct psycho-social assessments. He/She stated, "I did not know that the clinical director was supposed to do it."

ID PREFIX

TAG

N1304

N1408 290·4·2-.14(c) Individual Treatment Planning N1408 SS=D·

"Progress Notes. A program shall document the services received by· the client and document chronologically observations of the cllenrs 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 clienrs care, and shall be legible and recorded In the client's plan.

This Rule Is not met as evidenced by: Based on a review of client records and staff interview, it was determined that th'e facility failed to maintain progress notes that Included information regarding the clients' response to

·their treatment plan and the progress towards achieving each Individual goal and desired outcome for four' of four·sampled cllents.(#1· #4). Findings were: " ·

A review of client records on .8/28/2012, revealed that the progress notes of all four sampled clients did not Include detailed information regarding the effectiveness of their treatment plans and how the clients were progressing towards· meeting

PROVIDER'S PLAN OF CORRECTION (EACH CORRgCTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE · DEFICIENCY)

(X5) COMPLETE

DATE

State of qA Inspection Report. 'STATE FORM '"' G3D711 If oontlnuauon sheet 4 of a

· State of GA Healthcare Facilitv Requlation Division



C44-1C6-D


A. BUILDING B.~NG ________________ __



. 08129/2012 NAME OF PROVIDER OR ·sUPPLIER STREET ADDRESS, CITY, STAlE, ZIP CODE

NARCONON NEW LIFE AMBULATORY DETOX 6487 PEACHTREE INDUSTRIAL BLVD SUITE C & D DORAVILLE, GA 30360 .

{X4) 1D PREFIX

TAG




their goals. An example of the clients' progress notes was as follows: "Client feels good and Is making progress ... ". The progress notes did not Include statements of how the client responded to their treatment plan ·and what progress was made towards achieving their goals.

An Interview on 8/28/2012 at3:30 p.m., with the Case Supervisor, confirmed that the progress notes did not Include specific statements of how the clients responded to treatment and what progress was made towards the clients' goals.

N1902 290-4-2-.19(b) Ambulatory Detoxification SS=D Prog(ams

Staffing. Treatment Is provided by qualified medical staff a nil other professionals who are qualified by education, training, experience, and who are licensed/certified If required by state · practice acts to perform detoxification services that meet the needs of clients.

This Rule· Is not mel as evidenced by; Based on review of facility policy and procedure, employee records, and staff interviews, It was determined that the facility failed to have qualified. counselors to provide treatment for 15 of 15 clients (#1-#15), that were enrolled In the program. Findings were:

A review of the policy and procedure/job description for the facility. case supervisor on B/28/2012, revealed that the Case Supervisor would be qualified by education, training, experience, and hold a license/certification, If required by state practice acts to perform detoxification services.

A. review of th~ Case Supervlso~s employee

ID pREFIX

TAG

N1408

N1902

PROVIDER'S PLAN OF CORRECTION {EACH CORRI'CTIVEACTION SHOULD BE


(X5) COMPLETE

DATE

Stale of GA lnspecllon Report STATE FORM G3D711 If continuation sheet 5 of 6

State of GA Healthcare Facllitv Reaulation Division


(X1) PRDVIDERJSUPPLl~RICLIA IDENTIFICATION NUMBER:

044-106·0


A BUILDING 8, WING ________ _

PRINTED: D9i06/2012 FORM APPROVED


08/29/2012 NAME OF PROVIDER DR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NARCONON NEW LIFE AMBULATORY DETOX . 6487 PEACHTREE INDUSTRIAL BLVD SUITE·c & D DORAVILLE, GA 30360

(X4)1D PREFIX ·TAG




records (employee #6), revealed that there was no documented evidence that he/she was qualified by education, training, experience and/or was licensed or certificated to perform detoxification services andlor to provide supervl~lon of the detoxification program.

An Interview on 08/28/2012·at 3:30p.m., with the Executive Director, confirmed that the facility did

·not have any qualified substance abuse counselors on staff. The Executive Director stated," He/She ls.golng to assist with enrollment of staff into a local bridge program to complete certification."

N1904 290-4-2-.19(b)2. Ambulatory Detoxification SS;G Programs

Medical Coverage, There shall be a physician, nurse practitioner, physician's asslstan~ registered nurse, or licensed practical nurse with at least two years of substance abuse experience under RN supervision on duty during all hours of operation to provide or supervise client treatment and assess Individual clients as needed. Each physician employed by the program Is determined qualified by training, education, and experience to manage detoxification treatment and assumes responsibility for the medical services provided by the staff.

This Rule fs not met as evidenced by: Based on a review of the facility policy and procedure, staff record, and staff interview, It was determined that the facility tailed to have qualified medical coverage while the ·facility provided · treatment for 15 of 15 clients (#1-#15), enrolled In the program. Findings were:

' A review of the facility policy and procedure# ED

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N1902

N1904

PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE AQTION SHOUW BE


(X5) COMPLETE

DATE

State of GA lnspecUon Report STATE FORM G3D711 If con~lnua\lon sheet 6 of &

State of GA Healthcare Faclli!v Reaulatlon Division

SIAT(::MENT OF DEFICIENCIES AND PIAN OF CORRECTION

(X1) PROVIDER/SUPPLJER/CLJA IDENTIFICATION NUMBER:

044-106-D


· A. BUILDING B. \NJNG

PRINTED: 0910612012 FORM APPROVED

(X3) DATE SURVEY COM~LETED

08/29/2012

NAME OF PR_DVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CoDE


(X4) ID PREFIX

TAG·




40R revealed, that the facility's Staff Nurse, a licensed practical nurse(LPN), employee #4, must have at least two years of substance abuse experience, and work under the supervision of a R!'l (registered nurse), during all hours of operation. ·

A review of employee# 4's personnel record revealed no documentation that the LPN, had two years of substance abuse experience In managing a detoxification treatment program.

An interview on 8/28/2012 at 3:30 p.m., with the Executive Director, confirmed the facility did not have a qualified RN to supervise the LPN during all hours of operation.

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N1904

N1912 290-4-2-.19(e)2. Ambulatory Detoxification N1912 ss~o Programs

Within 48 hours of admission, a Detoxification . Care Plan shall be developed by a registered nurse, physician's assistant, or the physician. If not done by a physician, the development of the plan shall be supervised and signed by a.pbyslclan. Any changes to the plan must be documented in the plan and reviewed and signed by the physician. The plan shall address the nursing and med,ical procedures and monitoring activity needed to stabilize the client and to manage the withdrawal.

This Rule is not met as evidenced by: Based on review of the facility's policy and procedures, client record review, and staff interview, it was determined that the facility failed to implement a Detoxification. Care Plan within 48 hours of admission to include nursing and medical procedures and monitoring activities

PROVIDER'S PIAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE .


(X6) COMPLETE

DATE

State of G.(\ lnspeoUon Report STATE FORM G3D711 If e¢tlltnu8Uon sheet 7 of 6

State of GA Healthcare Facllitv Reaulation Division

STATEMENT OF DEFICIENCIES AND PlAN OF CORRECTION


044-106-D


A. BUILDING

B. VvlNG

PRINTED: 0910612012 FORM APPROVED


08/29/2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NARGONON NEW LIFE AMBULATORY DETOX 6487 'PEACHTREE INDUSTRIAL BLVD SUITE G & D DORAVILLE, GA 30360 .

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Ni912 Continued From page 7

needed to stabilize one of four sample clients (#1 ). Findings were:

A review of the facility policy and procedure# ED 33-1 on 8/28/2012, revealed that the clinical director shall ensure on admission areas of treatment or treatment problems that needed to be addressed would be outlined in the client's Detoxification Care Plan.

A review of the Detoxification Care Plan for client # 1 ( not dated ), signed by the Clinical Director, did not address information regarding the client's history of kidney disease that was documented on the admission history and physical asses~menl completed by the Medical Director on date 8/9/2012. The Detoxification Care Plan did not Include the additionili orders written by the Medical Director on 8/9/2012, requesting a follow-up and re-check of lab values In 2-3 weeks post admission.

An Interview on 8/28/2012 at 3:30 p.m., with the Executive Director, confirmed that the facility failed to develop a Detoxification Care Plan wllhln 48 hours of admission to lnclqde nursing, medical procedures and monitoring activities needed to stabilize the client.

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N1912

,!;.·~ .•



(X5) COMPLETE

DATE

State of GA Inspection Report SlATE FORM 8390 G3D711 If continuation sheet 8 or 8

I I

I '

David A . .Cook, Commissioner Nathan Deal, Governor

2 Peachtree Street, NW Atlanta, GA 30303-3159 I 404-856-4507 I www.dch.gsorgla.gov

September 6, 2012

Ms. Mary Riser, Administrator Narconon New Life Ambulatory Detoxification . 6487 Peachtree Industrial Boulevard Suite C & D Dora~ille, GA 30360

Dear Ms. Riser:

Enclosed is a report of the licensure inspection conducted at your facility on· August 28, 2012 by this office. The report contains one or more violations which must be corrected.

Your plan to correct these violations should be entered in the right-hand column entitled "Providers Plan of Correction" with a projected completion date entered in the column entitled "Completion bate." The completion date should not exce~d 30 days from your receipt of this correspondence. After you have completed the form, SIGN AND DATE it In the space provided at the bottom of the first page and return it to this office no later than ten days from the receipt of this letter. Please make a copy of this report for your . files.

Thank you for the courtesy extended to our representatives during the visit. If I can be of further assistance, please-contact my office at (404) 657-5421.

Sincerely,

Deborah Ferguson, MSN, RN Director Specialized Health Care Healthcare Facility Regulation Division Department of Community Hea.lth

DF:mab

Health lnforn'latlon Technology I Healthcare Facility Regulation I Medicaid I State Health Benefit Plan

Equal Opportunity Employer

Documents

DCH-GA-2012-10-29-Pur-O-Cleanse-MiscDocs_ocr