The late Patrick W Desmond
Below is a Georgia Department of Human Resources, Office of Regulatory Services inspection report on Narconon of Georgia, Inc from 5/16/2006, of which the followup reports are equally interesting and disturbing. There were more problems at this particular facility and it’s compliance than the State of GA knew at the time. They were and are still running a program that requires “students”, like the late Patrick W Desmond, to live in prearranged and contracted resident apts, with monitors to keep an eye on them depite what this and subsequent reports state.
More on that in my next post.
First, here’s short video of a Candle light Vigil held on July 11th in memory of Patrick, who died due to the negligence of the monitors “employed” and managed by Delgado Development and Narconon of GA.
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From State Form pgs 1-15 ( pg 16 was blank) Narconon of GA, Inc State facility License Evaluation- 5/16/06
Georgia Department of Human Resources, Office of Regulatory Services
Statement of Deficiencies and Plan of Correction
As of: Tuesday, February 19, 2008
Inspection begin date: 4/7/2006
Inspection end date: 5/16/2006
Name of Provider or Supplier
NARCONON OF GEORGIA
Street Address, City, State Zip Code
5688 PEACHTREE PARKWAY #B1 NORCROSS, GA 30092
Inspection Results
N 0000 Initial Comments:
At the time of the relocation and licensure survey, it was determined that Narconon of Georgia Outpatient Program was not in compliance with Chapter 290-4-2, Rules and Regulations for Drug Abuse Treatment and Education Programs. The following deficiencies were cited.
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.
Based on an application for relocation, 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’s 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 application, dated March 6, 2006, for a new license due to the facility’s move to a new location. The program modality requested 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, included a physical process of withdrawal from toxins and drugs through 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.
On site surveys related to the facility’s request for a new license were conducted on 4/7/06, 4/25/06, and 5/11/06.
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 through 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.
Policies and procedures provided lacked the training, qualifications and responsibilities of the staff supervising the purification phase, and how the process would be assessed and evaluated.
Seven of seven clients (#1, #2, #3, #4, #5, #6 and # 7) were observed 4/25/06 at 12:30 p.m., actively working on Step 2 of the program to include taking vitamins dispensed by the sauna/exercise staff in-charge ( I/C, employee #8), oils, salt, potassium, calcium and other supplements, in amounts significantly higher than the recommended daily allowances (RDA), during periods of exercise and sauna. The stated intent of this program step is to rid a person of the drug residuals and toxins and harmful effects.
Four out of four sampled records (#1, #2, #3 and #4) reviewed 4/25/06, 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 four sampled records lacked documentary evidence of continued medical oversight to include assessments or laboratory tests required, depending on the clients’ changing needs.
The administrator (employee #1) stated on 4/25/2006 at 12:30 p.m., that clients initiate daily treatment by filling out a “daily report form” with information that includes activities from the past 24 hours. Information filled out included the clients’ weight, vital signs, vegetables eaten, hours of sleep, running time, sauna time, vitamins or other supplements taken, emotional/physical changes, reactions, or discomforts.
The administrator further stated that clients discuss the information filled out on the “daily report form “with the sauna/exercise staff in-charge (employee #8) and then it is reviewed by the administrator (neither of whom are licensed medical professionals). Based on that reported information, special daily instructions are formulated in conjunction with guidelines identified in the “Clear Body Clear Mind, the Effective Purification Program” book (by L. Ron Hubbard).
Guidelines in the book included the tables by which unlicensed staff derived the vitamin and supplement doses for each client. There were no physician orders for the drugs.
The installation and operating instructions for the saunas, recommended by the manufacturer ” AMEREC, ” was provided by the facility and reviewed by surveyors on 4/25/06. The manufacturer’s (Amerec) recommended time to take a sauna was 5 to 10 minutes and the cooling time should equal time spent in sauna. The manufacturer recommended normal temperature inside the sauna room is 160 to 190 degrees. The temperature of the program’s sauna, detailed in a letter from the administrator 4/10/06, alleged the saunas were low heat saunas, with temperatures from 120 to 140 degrees. The program does not follow the manufacturer’s recommendations for use of the sauna in the purification component.
The Institute of Medicine’s upper limit of RDA for Niacin is 35 milligrams. The Institute of Medicine warns that Niacin taken in high doses is known to cause a wide range of adverse effects. The specific regimen of Niacin used in the Narconon program, not included in the application but noted on the clients’ daily report forms, far exceeds the RDA with potential risk to the clients.
The daily report form and the attached handwritten instructions from the administrator, for six out of seven clients (#1, #3, #4, #5, #6, and #7) who were active in the purification phase during the 4/25/06 survey, were obtained and reviewed during the 5/11/06 survey. The daily report form and instructions documented exercise and sauna time, vitamins or other supplements taken, reactions, questions or concerns of each client. There was no documented evidence of vital signs.
Examples of sauna use, vitamins and minerals taken, including Niacin taken that exceeds Recommended Daily Allowances and upper limit (UL) as reference by the Institute of Medicine were:
1. Review of three daily report forms for Client #1 revealed the following:
a) Documentation on 4/25/06 indicated that this was the client’s 6th day using the sauna. The report reflected that the client signed in the sauna at 1:20-out 2:00 (40 minutes); and signed in sauna 2:45-out 3:30 (45 minutes). Vitamins and supplements documented taken were: Niacin 400 milligrams(mg), [RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 10,000 international units (IU), [RDA 700 IU with UL 3,000 IU]. The client documented on the form that she/he was curious about reaching a dose of 5,000 mg of Niacin because she/he had a heart murmur. There was no documented evidence that this concern was addressed on the form.
b) Documentation on 4/26/06 indicated that this was the client’s 6th day (the 6th day was also written on 4/25/06) using the sauna. The report reflected that the client signed in the sauna at12:00-out 12:30 (30 minutes); signed in the sauna at 12:40-out 1:30 (50 minutes); signed in sauna 1:45-out 2:30 (45 minutes); signed in sauna 2:35-out 3:30 (55 minutes). Vitamins and supplements documented taken were: Niacin 500 milligrams (mg), [RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 20,000 international units (IU), [RDA 700 IU with UL 3,000 IU].
c) Documentation on 4/27/06 indicated that this was the client’s 8th day using the sauna. The report reflected that the client signed in the sauna at 12:00-out 1:15 (75 minutes); signed in the sauna at 1:20-out 1:55 (35 minutes); signed in sauna 2:25-out 3:05 (40 minutes); signed in sauna 3:10-out 3:35 (25 minutes). Vitamins and supplements documented taken were Niacin 600 mg (milligrams), [RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 20,000 international units (IU), [RDA700 IU with UL 3,000 IU]. The administrator documented a note to find out about ” heart murmur, ” and documented there is nothing in the medical report about a heart murmur.
none 2. Review of three daily report forms for Client #3 revealed the following:
a) Documentation on 4/25/06 indicated that this was the client’s 14th day using the sauna. The report reflected that the client signed in the sauna at 1:20-out 1:40 (20 minutes); 2:20-out 2:45 (25 minutes); signed in sauna 3:00-out 3:30 (30 minutes). Vitamins and supplements documented taken were Niacin 2000 mg (milligrams), [RDA 16mg with upper limit (UL) 35mg]; Vitamin A 30,000 international units (IU), [RDA 900 IU with UL 3000 IU] . The administrator documented a note to please get this client to a doctor; it sound like he has the flu. An additional note on the same page stated the client didn’t want to go.
b) Documentation on 4/26/06 indicated that this was the client’s 10th day (previous sheet day 14) using the sauna. The report reflected that the client signed in the sauna at 12:00-out 12:50 (50 minutes); signed in sauna 12:55-out 1:35 (40 minutes); signed in sauna 1:40-out 2:30 (50 minutes); signed in sauna 2:35-out 3:30 (55 minutes). Vitamins and supplements documented taken were Niacin 2000 mg (milligrams), [RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 30,000 international units (IU) [RDA 900 IU with UL 3000 IU].
c) Documentation on 4/27/06 indicated that this was the client’s 15th day (previous sheet was day 10) using the sauna; The report reflected that the client signed in sauna at 12:00-out 1:15 (75 minutes); Vitamins and supplements taken: Niacin 2500 mg (milligrams), [RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 50,000 international units(IU)[RDA 900 IU with UL 3000 IU].
3. Review of four daily report forms for Client #4 revealed the following:
a) Documentation on 4/26/06 indicated that this was the client’s 13th day using the sauna; The report reflected that the client signed in sauna 12:00-out 12:30 (30 minutes); signed in sauna 12:40-out 1:30 (50 minutes); signed in sauna 1:40-out 2:30 (50 minutes); signed in sauna 2:45-out 3:30 (45 minutes); Vitamins and supplements taken: Niacin 700 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; 500 mg, Vitamin A 20,000 IU[RDA 900 IU with UL 3000 IU].
b) Documention on 4/27/06 indicated that this was the client’s14th day in the sauna; signed in sauna 12:20-out 1:20 (60 minutes); signed in sauna 1:25-out 1:55 (30 minutes); signed in sauna 2:15-no time signed out; Vitamins and supplements taken: Niacin 700 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 900 IU with UL 3000 IU].
c) Documention on 4/28/06 indicated that this was the client’s 15th day in the sauna; signed in sauna 12:00-out 12:45 (45 minutes); signed in sauna 12:55-out 1:45 (50 minutes); signed in sauna 1:55-out 2:45 (55 minutes); signed in sauna 2:50-out 3:30 (40 minutes); Vitamins and supplements taken: Niacin 700mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 70,000 IU[RDA 900 IU with UL 3000 IU].
d) Documention on 4/29/06 indicated that this was the client’s 16th day in the sauna; signed in sauna 12:00-out 2:00 (120 minutes); signed in sauna 2:15-out (no time signed out); Vitamins and supplements taken: Niacin 700 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 900 IU with UL 3000 IU].
4. Review of three daily report forms for Client #5 revealed the following:
none a) Documention on 4/25/06 indicated that this was the client’s 6th day in the sauna; signed in sauna 1:20-out time is illegible; signed in sauna 2:30-out 3:00 (30 minutes); signed in sauna 3:10-out 3:20 (10 minutes); Vitamins and supplements taken: Niacin 400 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 10,000 IU[RDA 900 IU with UL 3000 IU].
b) Documention on 4/26/06 indicated that this was the client’s 7th day in the sauna; signed in sauna 12:00-out 12:45 (45 minutes); signed in sauna 12:50-out 1:40 (50 minutes); signed in sauna 1:45-out 2:30 (45 minutes); signed in sauna 2:40-out 3:30 (50 minutes); Vitamins and supplements taken: Niacin 400mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 10,000 IU[RDA 900 IU with UL 3000 IU].
c) Documention on 4/27/06 indicated that this was the client’s 8th day in the sauna; signed in sauna 2:30 with no other documented entries for the day noted; Vitamins and supplements taken:
Niacin 500 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 900 IU with UL 3000 IU].
5. Review of four daily report forms for Client #6 revealed the following:
a) Documention on 4/24/06 indicated that this was the client’s 11th day in the sauna; signed in sauna 12:30-out -1:10 (40 minutes); signed in sauna 1:20-out 2:00 (40 minutes); signed in sauna 2:10-out 2:45 (35 minutes); signed in sauna 3:00-out 3:30 (30 minutes); Vitamins and supplements taken: Niacin 700 mg (milligrams)[RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 700 IU with UL 3,000 IU].
b) Documention on 4/25/06 indicated that this was the client’s 23rd day in the sauna (day in sauna does not coincide with date); signed in sauna 1:20-out -1:40 (20 minutes); signed in sauna 1:4?(illegible)-out 2:00 (unknown minutes); signed in sauna 2:25-out 2:55 (30 minutes); signed in sauna 3:05-out 3:30 (25 minutes); Vitamins and supplements taken: Niacin 800 mg (milligrams)[RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 700 IU with UL 3,000 IU].
c) Documention on 4/26/06 indicated that this was the client’s 14th day in the sauna (day in sauna continues to not coincide with date); signed in sauna 12:00-out 12:45 (45 minutes); signed in sauna 12:50-out 1:30 (45 minutes); signed in sauna 1:35-out 2:30 (55 minutes); signed in sauna 2:35-out 3:30 (55 minutes); Vitamins and supplements taken: Niacin 900 mg (milligrams)[RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 700 IU with UL 3,000 IU].
d) Documention on 4/27/06 indicated that this was the client’s 14th day in the sauna (day in sauna continues to not coincide with date); signed in sauna 12:20-out 12:50 (40 minutes); signed in sauna 1:00-out 1:30 (30 minutes); signed in sauna 1:35-out 1:55 (20 minutes); signed in sauna 2:00-out 2:30 (30 minutes) signed in sauna 2:35-out 2:55 (20 minutes); signed in sauna 3:00-out 3:30 (30 minutes); Vitamins and supplements taken: Niacin 900 mg (milligrams)[RDA 14 mg. with upper limit (UL) 35 mg]; Vitamin A 20,000 IU[RDA 700 IU with UL 3,000 IU].
6. Review of three daily report forms for Client #7 revealed the following:
a) Documention on 4/24/06 indicated that this was the client’s 9th day in the sauna; signed in sauna 12:30-out 1:15 (45 minutes); signed in sauna 1:25-out 2:10 (45 minutes); signed in sauna 2:15-out 3:00 (45 minutes); signed in sauna 3:10-out 3:40 (30 minutes); Vitamins and supplements taken: Niacin 700 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 20,000 IU)[RDA 900 IU with UL 3000 IU].
b) Documention on 4/25/06 indicated that this was the client’s 10th day in the sauna; signed in sauna 1:20-out 1:40 (20 minutes); signed in sauna 2:00-out 2:45 (45 minutes); signed in sauna 3:00-out 3:30 (30 minutes); Vitamins and supplements taken: Niacin 800 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 20,000 IU)[RDA 900 IU with UL 3000 IU].
c) Documention on 4/26/06 indicated that this was the client’s 9th day in the sauna (day in sauna does not coincide with date); signed in sauna 12:00-out 12:40 (40 minutes); signed in sauna 12:45-out 1:35 (50 minutes); signed in sauna 1:40-out 2:30 (50 minutes); signed in sauna 2:35-out 3:30 (55 minutes); Vitamins and supplements taken: Niacin 800 mg (milligrams)[RDA 16 mg with upper limit (UL) 35 mg]; Vitamin A 20,000 IU)[RDA 900 IU with UL 3000 IU].
The Institute of Medicine RDA UL for Niacin is 35 milligrams. The Insitute of Medicine warns that niacin taken in high doses is known to cause a wide range of adverse effects.
The program description specified Narconon of Georgia functioned at an (The American Society of Addiction Medicine) ASAM III.3 level. This level is a residential intensive treatment program that does not include a detoxification component. The administrator (employee #1) confirmed during a telephone interview on 5/16/06 at 10:30 a.m., that Narconon’s policy stated the program did not provide housing for its clients.
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.
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.
Based on observation, 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. The findings were:
The program description specified Narconon of Georgia functioned at an (The American Society of Addiction Medicine) ASAM III.3 level. This level is a residential intensive treatment program that does not include a detoxification program. The observed facility program contradicts the outpatient treatment protocol submitted, the program description, the submitted policies and procedures and the findings identified throughout the day of the survey.
The submitted program description, including provided policies and procedures, did not specify the amounts of excessive vitamins, minerals, oils, other supplements, and the extent of the 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 training, qualifications and responsibilities of the staff supervising the purification phase, and how the process would be assessed and evaluated, were not stated in approved policies and procedures.
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.
Based on a review of records, observation, 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 potentially harm for all clients. Findings were:
The program used L. Ron Hubbard’s, “Clear Mind-Clear Body” as the protocol for Step 2 of the program, the purification phase.
Seven of seven clients (#1, #2, #3, #4, #5, #6 and # 7) were observed on 4/25/06 at 12:15 to 2:55 p.m. actively working on Step 2 of the program to include taking vitamins dispensed by the sauna/exercise staff in-charge ( I/C, employee #8), oils, salt, potassium, calcium and other supplements, in amounts significantly higher than the recommended daily allowances (RDA), during periods of exercise and sauna. The stated intent of this program step is to rid a person of the drug residuals and toxins and harmful effects.
Four out of four sampled records (#1, #2, #3 and #4) reviewed 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 four sampled records 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 of the program.
The administrator (employee #1) stated on 4/25/06 at 12:30 p.m. that clients initiate daily treatment by filling out a “daily report form” with information that includes activities from the past 24 hours.
Information filled out included the clients’ weight, vegetables eaten, hours of sleep, running time, sauna time, vitamins or other supplements taken, emotional/physical changes, reactions, or discomforts.
The administrator stated, on 4/25/06 at 12:30, that clients discuss the information filled out on the “daily report form”with the sauna/exercise staff in-charge ( I/C, employee #8) and then it is reviewed by the administrator (employee #1) (neither of whom are licensed medical professionals).
Based on that reported information, special daily instructions are formulated in conjunction with guidelines identified in the “Clear Body Clear Mind, the Effective Purification Program” book (by L. Ron Hubbard). Guidelines in the book include the tables by which the vitamins and supplements doses were derived for each client.
The administrator stated that clients take their own vital signs (no staff was observed watching or evaluating the vital signs), clients are given individual doses of Niacin, based on the vitamin table in the book “Clear Body Clear Mind” (by L. Ron Hubbard) which range from 100 mg to 5,000 mg (the recommended daily doses for males age 19 to 70 is 35 mg), are driven to a nearby state park to run/walk 10-20 minutes to get the blood circulating, and then are driven back to the facility.
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 four of four sampled clients (clients #1, #2, #3, and #4). Findings were:
Review of client records on 4/25/2006, revealed that all four sampled clients did not have individualized treatment plans. All four sampled clients had the same three pre-printed goals written in their treatment plans. The goals were:
1. By the end of 7 days, client will be completely free from abstinence symptoms with the withdrawal specialist in charge documenting completion.
2. Client will have completed all practicals in book one with a noticeable improvement in their ability to confront and communicate and resolve problems.
3. Client will have Oxford capacity analysis (OCA) completed pre and post sauna and documentation of the successful completion of book 2.”)
During an interview on April 25, 2006 at 3:00 p.m., the administrator (employee #1) was informed of this finding and admitted the facility did not individualize client treatment plans.
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:
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 record review and staff interview, it was determined that the facility failed to formulate a comprehensive treatment plan by a multidisciplinary team for four of four sampled clients (client #1, #2, #3, and #4). Findings were:
