OoJtMUN:ttY

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
(twne of Governing Body)
to maintain and operate a DRUG ABUSE TREATMENT AND EDUCATION PROGRAM with 0 branch named as
- -----
NARCONON NEW LIFE AMBULATORY DETOXIFICATION
(Name of Facility)
Approval is granted to provide the following programs: OUTPATIENT AMBULATORY DETOXIFICATION PROGRAM
said facility and premises are located at
in
____ D....,O,....RA --=- Vf _L..,.... L_E ____ , Couniy of
(City or Town)
This permit is effective
ASAM Levels:
11-D
6487 PEACHTREE INDUSTRIAL BLVD SUITE C & D
DEKALB

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 Heslth, Official Code of Georgia. Title 26, Chapter 5, and
signifies that the provider complies with the Rules and Regulations of tiM Department of Community Health on the date this license was issued."
THIS PERMIT IS NOT TRANSFERABLE
PennitNo: 044-106-0
GEORGIA DEPARTMENT OF COMMUNITY HEALTH HEALTHCARE FACILITY REGULA nON DMSION
.. -- ---------------------------------------------------------------

H'E'.&. ... :'i"'9'
STATE" OF GEOR.GIA
. ';&jzq. .
..... -_.....
DRUG ABUSE TREATMENT AND EDUCATION PROGRAM PERMIT
to maintain and operate a
\ /
Said and :ara located at e487 INDUSTRIAL BLVD SUiTE C & D
(St:rMt}
___ D_E_KA.LB __ Georgia. in DORAVILLE
(Q{yorTown)
' This permit i:; and remains in effeCt unless revoked or suspehded..
""This permit is granted pursuant the authOrity vested ln the Department of Commun Health, Official Code of Georgia, Title 26, 5, and
-signmes that the co tes with tbe Rules and Regulations of the Department of Community Heatth on the elate this license was issued."
. . 044-106--D . .
FACILITY REGULATION DIVISION
SPECIAL.IZED CARE SECTION
2 PEACHTREE STREET N. W
SUIIE 31.447
ATLANTA, GA 30303-3142
OCT 2 6 2012
m:cmm
APPLICATION FOR A UCll!NSE TO OPSRAYE A DRUG ABUSt= TREATMENT AND PRO<;iRAM
Pvn;uant lo provl$lon of O.C.G.A.26S1 et seq. Applics(!on Is hereby made lo operat(j th& Drug Abuse Treatment and fducadon Program Which identlfled as
follows (6eparate application 111qulrlid fol' each progrom locatiott subject to llc<>nsura}: Effacllva AlJgu:Jt a a fvo must be paid for u11Ch now application,
chrmge of ownership. change of loculian, Gr rMewa/ Qf lic:anse. Before JIOU apply for any nsw applh:11Cion or chenges, please downiOiJd the payment
coupon an" iillbmlt rne corteQt p;wment to lhs1i1allbGX on ths coupon fomr. Then, please follow the dlrec:rlons for tho application below.
A. ldontlflcatlon
Type of lnltlal Renewal Update/Chanoe of staws(explain): X Chan!j!e status of Narconon
New Life Ambulatory Detoxlfloatlon from branch to full 7 day a week operation with its own licence
Parent: SUI:IUI'Iils (I) Branches (#)
Type;
(sep. applications required attach)
Accreditation Status: . (optional) E=xplrauon date
Narconon New life AmbUlatory Detoxification Program 67'8-580-4922
Name of Program Phone
6487 Peachtree industrial Blvd. Suite C and D Doraville Dekalb 30360
Streat Address (where prolllded) City Zip
Li$1 addteS$8$ of all sttcs, Including apartment numbers
5688 Peach1ree Parkway Norcross GA 30092
newlifedetox@naroononga.org
Pto91'am Mailing
Narconon of Georgia Inc.
official Name of Gcw$mlng Body
Mary Rieser Robin Muse LPC
Admlnl6\t.ltor (appointed by Governing Body) Clinical Dlreclor
Section 6. OwnGrshlp lntonnatlon- Qf Ownorship
Non..Prollt
1::-maU
Aaron Anderson
Proprietary Profit
Individual
___ Plll'tnership
State

---City
Service Board

___ Corporation Onetude copy of
ceriificate of incorporation)
___ Hospital Authotlly
Other (specify) . 501(c) S NonProflt
Corporation
_--:. X.-.. Othar (specify)
List names and addresses of ali owners above with fiVe percent (5%) or more Interest, or oflicerG of a corporation or paJ1nm of a partnership, as
applicable (attach additional sheett; If nacessary)
Not applicable -Non
section C. Modalltkls Provldod (check alltoc:atod at program addres5 section A)
Outpatient Amb. Detox X
Intensive (if)
Day Treatment
Datox Resklerttlal Beds: Transitional (ffl
Subunit Branch (part lima, a part of a full-time lloeneed pro9ram)
Pa!'el'lt name and license'
Populations serve!!: male X
adUlt __ x __
Special Program (explain)
female

X
(required for subunits and branches)
{approx #)
children
wfood service
ape range
.. ,
Soctlon c. (continued)- ASAM Patlont Plae$ment Orlterl:!
Outpalienl servloos
U. 1 Intensive outpatient
11.5 (circle ono} Partial hospltalizallon
Day 'rreatmant and Outpatient
IID Ambutato.y delox wl extended on-&1\e monltorin!J
Ill. 1 (drcle ono) Cllolc$1\y-managed low Intensity
Aesldential Traneitional
Section (assigned to program add"'&s soctlon A)
Counselor I Therapist I Social Worker (certified or license.:!)
Counselor (not eenlfled or licensed)
Consultants (specify type)
Registered N!.lrses
X
111-2-D.
(circle one)

(clrclo onll}
lll.!l
(c;lroJa ons}
#1'1.111-tlml.'>
NA
Clinically-managed residenUal datox
Residential $1.4bacute
Ambulatory Detox
CUnicallyITlllnaged medltJm lnlenaily

medlhigh iotenslly residential
Resldenliallnlen&ity
#part-time
1
2
total hra/wk
5 & 24 Hours on call
35
3 35
Licensed Prac!ioal Nlfies
None now. Will use as PRN if quallffe<l

Administrative Pt.lrsonne! 25
MGdlcal Director (name)
other (specify)
Dr. Locamini Available for appointment 10 am-5 pm Mon-Sat. 24 hour on call
Section o. (eslgned to progrant add1'9$S section A)
Number of hours each \111aak that Drua Traatmeni & Education Services are scheduled:
Hours earm week that a phyBician, physicl&n'tl assistant or nurse scneduled to be pre$EII'lt:
Speclflc days/hours of opel'atlon for the provision of Drug Treatment &
Minimum numbM of program staff present during operating hours:
Current number of active Drug TrGatmsnt & E:dueatlon Clielrt6:
Services other ltlan Drug Treatment & Education proVidad at this location:
Section F. Required Attaebmonts
Comprehensive OuUine (InClude ASAM tevGI/s included at this location)
Proof of compliance with taws tor han<lill'\9 and dispensing of drugs
Proo1 o1 compliance with applloabl$ $tate &.local health, safely, sanitation. & zoning codes
Affidavit of lawfUl Presence In Unlled States
42
35
7 days a week 9 am-3 pm
two
16
none
Dale of Signature r- ,.
j]r-;,4'4:)
. FOR STATE USE: ONLY
OaiG Raceived:
Approved us:
Section I Unit Dirlilclor Approval I Comments;
Reviewed by;
Effective Dates:
Tille

" .
f'
HEALrH CARE FACILITY REGULATION
SPECIALIZED CARE SECTION
2 PEACHTREE STREET N.W.
SUITE 31.447
ATLANTA, GA
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, 2010
1
a foo bfJ pnld for each new appJiGallon
1
cllrm{la ownarsfllp, cllange of loaatlon, ot
r&n9wal of 1/censo. apPlY for any new app/lcaUon or cllangos, dawnlottd (he payment coupon and
submit tht'l (:Oftect pa:yme to tlla JJiallbox on the coupon form, Then
1
(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 (#) __ applications raqulred ... afltwh)
Aocredltatlon status: (optional) expiration dale
__ .(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(apolfy) 501 (c) 3 r,<ron-pl'Dfit
Aal'O!I Andesou
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
C. Program Modalllle.s Provided (chec!( all located at program ciddrass section A)
Outpatlenl_____..Amb. 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#;_ __________
for subunlls and branohes)
Populations sorvcd: __ _
IKfuiL..X...-.Bdolesoent..,..__..chlldrel\....___,8g9 ran.go 10 66
Spealal Proljrwn(explaln):. _ ______ ________ _ _ _ ____ _ _
Seotlon D. F'orsonnal (aoolgned to program address section A):
Counselor fThoraplsl / 800141 Workor (cerlflletl or Jicensod)
(;(lunonlc.r (notlloonsod or oor111fod)
Oonetdlnnts (npoalfY typ&)
Re.g!Blerttd NutBeu
NA
11patt-thno lolof
5 & 24 hours oh oall
2 35
3 36
Lloensed PcaoUoal Nurses None I lOW. Wlll Usu oa PRN If ((UQIIIIad.
Admlnllllr!!Uvo Pornonnof 1 25
Prur1wn. Dlruotor 1 rua tlmo ovemlohr
Modic ill Olreor (llllhle)
Olhar(speolfy)
Dr. Locnminl Avllilable for appointmont J Oarn-5ptn MonSnt. 24 hom on call
Soc don E. PrognthllllfoJmaUon for services provided ot thlo locat1011:
Nutnher of uw:h Waal( thnl Drug Treabnenl & Edlloallon Setvlods ure ochodulod: 42
Hours each week that u physician, physldan's !lllsidi!Wcr nurae achodl.1od to bo present: 35
Speclliodaysllloura ol operallon for lhe prO'IIslon of Drug Treatlll&nt & Educallon: BIW8n daya a week Dem-3 pm
Mlnlnwm numbor or progrem stoltpresenl dlulr'(l q>eralin({houra: two
Currsnt numbc)r 0( ooll\lo Drug Trealmelll & Edtioa\lon .C)Iente: 16
Sof\llccv olhcr than Drug Treatment & Eduoallon provldad 1lt Ill is looatlon: NONE
Socllon f. RBqull'ed Attachments per O.C.G.A. 28-56:
Comprehen1Ve P/'OIIrllm Ouurne (lnolude ASAM le'ie'Je proVIded localfon).
Proor of oompllanoo Wllh IHWS for the handling and dlspone!ng of <ltUQB.
Prouf of w11h opplloablo & loOt!/ heallh. aafflly, sanltaUon, bulltllng & r.onlng oudoe,
BeoUon G. CorlllloolkilJ:
I certify I hal this faolllty will oo111ply wUIIhe RUlelJ and Regukllloo$ for Drug 1i'MIInenl and EdUcAIIon ProorniTI&.
lundorolnud that a Uoe11so IG non-l{allGforeble and mmt bo retvrned to Healfhoaro Faolflty Rogu(QIIon If a progrnm
I certify loollhH 11bove lrlfotmlllfonls I rue lo tllO bo&t of my knnWJodoe.
'-.2o -c

Ete.LtJ -b (A.!J.,. ;{)i'ce
Thle
FOR STATE USE ONLY
Dale Ret.elved._ Re\llewed by.,__ __ .....;.. __________ _
Approved aa:_ dates:. ___
Seotton/Unlt Director
02/06
-
State of GA Healthcare Facilitv Reaulation Division
PRINTED: 09/08/2012
FORM APPROVED
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONsmiJCTION
(X3) DATE SURVEY
COMPLETED
A. BUILDING
044-1060
B.IMNG
08/2912012
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
NARCONON NEW LIFE AMBULATORY DETOX
6487 PEACHTREE iNDUSTRIAL BLVD SUITE C & 0
DORAVILLE, GA 30360
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
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 (CAG), or must be
actively working towards obtaining certification as
aCAG.
A review of the Sauna IC's personnel record (staff
# 2) revealed no documentation that he/she was
a GAG, or was working towards obtaining
certification as a GAG,
An Interview with the facility's Executive Director
and the.sauna ICon 8/28/2012 at 3:00p.m.,
confirmed that the Sauna IG was not actively
working towards becoming a Gf\C. The Executive
State of GA lnspecUon Report
ID
PREFIX
TAG
NDOO
N1DOO
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLieR REPRESENTATIVE'S SIGNATURE
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
TITLE
(X6)
COMPLETE
DATE.
(X6} DATE
STATE FORM '"' G3D711
If contfnuat!on sheet 1 of 8
State olGA Healthcare Facllitv Reaulatlon Division
STATEMENT OF DEFICIENCIES
AND PlAN OF CORRECTION
(X1) PROVIDERISUPPLIERICLIA
IDENTIFICATI<:lN NUMBER:
044106-D
(X2) MULTIPLE CONSTRUCTION
ABUILDING
B. WING
PRINTED: 09/06/2012
FORM APPROVED
(X3) DATE SURVEY
COMPLETED
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
SUMMARY 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 2904-2.10(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 employeerecord # 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 onB/28/2012 at 3:15p.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 lnspeol on Report
STATE FORM G30711
If continuation sheet 2 of 8
State of GA Healthcare Facility Requlatiori Division
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
NAME OF PROVIDER OR SUPPLIER
(XI) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER:
044-106-D
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING ________ _
STREET ADDRESS, CITY, STATE, ZIP CODE
NARCONON NEW LIFE AMBULATORY DETOX
6487 PEACHTREE INDUSTRIAL BLVD SUITE C & D
DORAVILLE, GA 30380
PRINTED:.09/06/2012
FORM APPROVED
(X3) DATE SURVEY
COMPLETED
08/29/2012
(X4)1D
PREFIX
TAG
SUMMARY STATEMENT OF DgfiCIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FUlL
REGULATORY OR LSG IDENTIFYING INFORMATION)
ID
PREFIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
IX5) .
COMPLETE
DATE
N1304 Continued From page 2 N1304
N1304 290-4-2-.13(1)(b)2. Client Referral, Intake, N1304
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 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 personnel
records on 8128/2012, revealed no documented
State of GA lnspecUon Report
STATE FORM G3D711
If continuation sheet 3 of 8
State of GA Healthcare Facility Requlatlon Division
SYA YEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDERJSUPPLIERICLIA
IDENTIFICATION NUMBER:
044106-D
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. WING---------
PRINTED: 09/06/2012
FORM APPROVED
(X3) DATE SURVEY
COMPLETED
08/29/2012
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, SOAYE, 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 29042-.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 foursampled 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 SHOUUO 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 Facility Regulation Division
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDERISUPPLIERICUA
IDENTIFICATION NUMBER:
044-106-D
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
________________ __
PRINTED: 09/06/2012
FORM APPROVED
(X3) DATE SURVEY
COMPLETED
. 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
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
N1400 Continued From page 4
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 stale
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 Case employee
ID
pREFIX
TAG
N1408
N1902
PROVIDER'S PLAN OF CORRECTION
(EACH CORRI'CTIVEACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
Stale of GA lnspecllon Report
STATE FORM G3D711
If continuation sheet 5 of 6
State of GA Healthcare Facllitv Reaulation Division
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1)
IDENTIFICATION NUMBER:
044-106-D
(X2) MULTIPLE CONSTRUCTION
A BUILDING
8, WING ________ _
PRINTED: D9i06/2012
FORM APPROVED
(X3) DATE SURVEY
COMPLETED
08/29/2012
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
NARCONON NEW LIFE AMBULATORY DETOX
. 6487 PEACHTREE INDUSTRIAL BLVD SUITEc & D
DORAVILLE, GA 30360
(X4)JD
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
N1902 Continued From page 5
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
of the detoxification program.
An Interview on 08/28/2012at 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
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
ID.
PREFIX
TAG
N1902
N1904
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE AQTION SHOUUl BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
State of GA lnspecUon Report
STATE FORM G3D711
If sheet 6 of &
State of GA Healthcare Facility Division
SYAT!:MENT OF DEFICIENCIES
AND PLAN Or COFli'!ECilON
NAME OF PROVIDER OR SUPPUER
(X1) f'ROVIDERISUPPLIER/GLIA
IDENTIFICATION NUMBER:
044-106-D
(X2) MULllPl.E CONSTRUCTION
A. BUILDING
13. INING - ---'-------
STREI:r CITY, STATE, ZIP CODE
NARCONON NEW LIFE AMBULATORY DETOX
6487 PEACHTREE INDUSTRIAl BLVD SUITE C & D
DORAVILLE, GA 30360
P.RINTED: 09/06/2012
FORM A.PPROVED
(Xl) DATE SURVEY

Oll/29/2012
(X4) ID
PREFIX
TAG
SUMMARY S1'AlEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FUlL
RI::GUI.ATORY OR I.SC IDENTIFYING INFORMATION)
10
PREFIX
TAG
PROVlOER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
Q<O)
CONPI.ETE
OATE
N1904 Continued From pag& 6 N1904
, 40R revealed, that the facnlty's Staff Nurse, a
licensed practlcalnurse(LPN), employee #4, must
have at least two years of substance abuse
experience, and work under t he supervision of a
RN (registered nurse), during all hours or
operatlory.
A revlew of employee# 4's personnel record
revealed no documentation that the LPN, had
two years ot substance abuse experience In
managing a detoxlflcaUon treatment program.
An interview on 8/28/2012 at 3:30 p.m., with the
Executlve Director, confirmed the facility did not
have a qualified RN to supervise the LPN durh'g
all hours of operation.
N1912 290-4-2-.19(e)2. Ambulatory Detoxlflcatton N1912
SS=D Programs
Within 48 hours of admission, a Detoxltlcatlon
. 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
Any changes to the plan must be documented in
the plan and
reviewed and slgoed by the physician. The plan
shall addfass the nursing and medJcal
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
State of GA nspooUon Report
STATE FORM G3D711
II oonllnuWion sheet 7 ol8
State of GA Healthcare Facllitv Reaulation Division
STATEMENT OF DEFICIENCIES
AND PlAN OF CORRECTION
(X1) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER:
044-106-D
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B. VvlNG
PRINTED: 0910612012
FORM APPROVED
(X3) DATE SURVEY
COMPLETED
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 .
(X4)1D
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGUlATORY OR LSC IDENTIFYING INFORMATION)
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
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.
ID
PREFIX
TAG
N1912
.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
State of GA Inspection Report
SlATE FORM
8390
G3D711
If continuation sheet 8 or 8
I
I
I
'
A .. Cook, Commissioner Nathan Deal, Governor
2 Peachtree Street, NW Atlanta, GA 39303-3159 1 404-656-4507 www.dch.georgla.gov
September 6, 2012
Ms. Mary Riser, Administrator
Narconon New Life Ambulatory Detoxification ,
6487 Peachtree Industrial Boulevard Suite C & D
GA 30360
Dear Ms. Riser;
Enclosed is a report of the licens4re inspection conducted at your facility on' August 28,
2012 by this office. The report contains one or mora violations which must be corrected.
Your plan to correct these violations should be entered jn the right-hand column entitled
"Providers Plan of Correction" with a projected completion entered in the column
entitled "Completion bate." The completion date should not 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 mal<e 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'laUon Technology I Healthcare Facility Regulation I Medicaid I Stale Health Benefit Plan
Equal Opportunity Emj:Jioyer