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"There's a range of quality," Hester admits. "There's a number of providers that I think need technical assistance. And there are some safety issues, some real basic safety issues."
DHR inspectors visiting Atlanta Metro Treatment in Norcross found in February 1999 that the clinic was breaking nine state rules, ranging from overflowing trash cans and "an infestation of flying insects" to a clinic director who "did not seem familiar with some of the basic principles of substance abuse treatment." Inspectors made 13 recommendations for improvement and concluded, "There is much work to be done to bring this program into compliance."
Inspectors returned 10 months later and found that the clinic had one counselor handling all 187 patients (state rules require that there be at least one counselor per 40 patients). The DHR recommended that the clinic stop admitting new patients.
Atlanta Metro director Jerry Walters, who was hired last October, says the state has visited the clinic since his arrival, although CL found no documentation of that visit in state files. Walters says he has worked to come up with a new plan that meets state regulations and that the clinic has almost a whole new staff, including five counselors for the current 235 patients. That's still a counselor short of the counselor-to-patient ratio required by the state.
Cartersville Treatment Center was inspected by the DHR in August 1999 "when this office was informed that the medical director had resigned and had major concerns about program operations," Hester wrote. The state found that the clinic was without a physician for 17 days and that patients were getting dose increases without the required medical signature. Patients also complained that staff members didn't know what they were doing.
Cartersville director Troy Beaver says the inspectors returned a year later to interview him but have not conducted a follow-up inspection. Beaver referred further questions to the center's corporate office in Tennessee.
At GPA Treatment Center in Doraville, a patient caught selling methadone was allowed eight take-home doses the next month. Counselors, not physicians, had been writing medication orders for four years, according to a 1995 inspection report. For three days, the pharmacy door was left open. "The program's accountability for methadone was very poor," the DHR noted.
At the end of that inspection, the DHR listed more than a dozen violations and eight recommendations for improvement. Hester wrote: "It should be noted that all of the above recommendations concern serious violations of applicable rules and regulations." The letter urged the clinic to "take all steps necessary to come into compliance with all applicable state and federal rules and regulations."
That letter was sent shortly after the 1995 inspection. The DHR did not check on the clinic again until November 2000.
GPA Treatment Director Stacey Pearce says state inspections, although thorough, are arbitrary and misleading. She points out that during her clinic's November inspection, which revealed few violations, she was cited for allowing a patient to take home 27 doses of methadone (the limit is currently six). She then produced a signed document that showed she had received both state and federal approval for that specific patient.
"The relationship between the state and the clinics is very adversarial," she complains. "It's not a good relationship."
Pearce describes some state rules as "unenforceable." First-time patients are required, for example, to prove they have a one-year addiction to opiates. Pearce, whose mother owns the clinic and who started work there as a receptionist five years ago, argues that a drug-use history of that length is impossible to verify. "I can't contact everybody's drug dealers," she says.
To screen incoming patients, she says GPA tests their urine for opiates. Beyond that, if someone claims to be using heroin and has track marks, he gets methadone. She says someone who shows that he has prescriptions for pain pills at multiple pharmacies also will get dosed.
If someone has neither track marks nor prescriptions, if he claims to be addicted to pills he buys on the streets, Pearce says, "we basically have to go on their self-report."
Both addicts and recreational drug users have found ways to take advantage of lax enforcement of rules.
"You walk in with $10 and a picture ID, and you're high for two days," Reeves says of opportunistic patients he knows at one Atlanta-area clinic. "You take a drug test, but it doesn't come back for a week. It takes 30 minutes to get dosed. I didn't even see a doctor."
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