UHS of Provo Canyon Springville Campus

Out of compliance, investigation inspection : R380-80-5(3) Provider shall comply with policies and safe practices

The provider was out of compliance with R380-80-5(3) for failing to comply with written policies and safe practices that address the appropriate treatment of clients. During the inspection, the provider reported that their staff member gave a sweater, journal, and a letter containing his personal contact information to a client who was discharging from the program. This staff member failed to comply with the provider's written Employee Professional Conduct policy that states “staff/patient interactions are treatment-focused only; no personal relationships during or after treatment. Staff personal information (last name, telephone number, address, email, etc) is considered private and should not be shared with patients”. This is a repeat noncompliance as noted on April 23, 2025, June 2, 2026 and July 1, 2026.

Out of compliance, conditional, monitoring inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(b) for failing to ensure that each client has the right to be treated with dignity and respect. During the inspection, the investigator conducted a walkthrough of the facility observing disrespectful graffiti present on walls in occupied living units and in the bathroom. This is a repeatcitation as noted on June 2, 2026.

Out of compliance, investigation inspection : R380-80-5(10) Services and supervision to meet each clients needs

The provider was out of compliance with R380-80-5(10) for not providing services and supervision commensurate with the behaviors and needs of each client. During the investigation inspection, the evidence substantiated through facility video coverage and provider records that on June 26, 2026, a client with a documented history of end-of-life attempts, self-harm, and ingesting unsafe items was given access to a cordless telephone. The client swallowed the device's battery, which required emergency medical transport to a hospital. This is a repeat noncompliance previously noted on 06/02/2026.

Out of compliance, complaint, investigation inspection : R380-600-7(6) No withholding or manipulating sources

The provider was out of compliance with R380-600-7(6) by failing to ensure the integrity of OL’s information gathering was not compromised when it withheld or manipulated information related to several events reported to OL. During inspection, the investigator learned of multiple incidents where the provider withheld material information in its required critical incident reports. Examples include, but are not limited to, one incident involving a client who had been put into a restraint. Video footage shows that the provider withheld material information required in the critical incident report and did not accurately represent the events as depicted in the video footage. In another example, the provider withheld material information about the extent of a client’s injuries from self harm.

Out of compliance, complaint, investigation inspection : R380-600-7(16)(a)-(e) Critical incidents reporting requirements

The provider was out of compliance with R380-600-7(16)(a) by failing to submit 7 reports of a critical incident to OL. During the inspection, OL reviewed the provider’s internal incidents dated May 20, 2026 through June 17, 2026. The Office of Licensing identified 7 critical incidents that were not reported to OL. These incidents are dated May 20, 2026, May 23, 2026, June 1, 2026, June 1, 2026, June 1, 2026, June 2, 2026, and June 17, 2026.

Out of compliance, complaint, investigation inspection : R501-19-4(4)(a)-(j) Supervision and ratio requirements

The provider was out of compliance with R501-19-4(4)(e) for failing to increase the staff-to-client ratio as necessary to ensure the health and safety of their current client population. During the inspection, the investigative interviews confirmed that staff to client ratios were insufficient to manage aggressive client behaviors of the current client population. Video evidence shows clients overwhelming staff by using distractions, engaging in physical assaults against staff, and attempting to seize staff keys and radios, which directly resulted in staff injuries and extensive property damage.

Out of compliance, complaint, investigation inspection : R501-19-4(4)(a)-(j) Supervision and ratio requirements

The provider was out of compliance with R501-19-4(4)(e) for failing to increase the staff-to-client ratio as necessary to ensure the health and safety of their current client population. During the inspection, the investigative interviews confirmed that staffing levels were insufficient to manage aggressive client behaviors. During one event, video evidence showed clients overwhelming personnel by using distractions, engaging in physical assaults against staff, and seizing staff keys in an attempt to elope. Even after staff called for additional staff to come assist, the staff were not able to ensure the health and safety of the current client population. Clients ran to each unit, enticing their peers to join them. Throughout this event, various staff attempted to stop them and retrieve the keys, but failed. Seven clients were able to elope from the facility.

Out of compliance, complaint, investigation inspection : R501-1-15(1) Adequate staffing for supervision

The provider was out of compliance with R501-1-15(1) for failing to ensure enough staff to safely manage behaviors, dynamics and supervision needs of the current population. During the inspection, the investigative interviews confirmed that staffing levels were insufficient to manage aggressive client behaviors. Video evidence showed clients overwhelming personnel by using distractions, engaging in physical assaults against staff, and seizing staff keys in an attempt to elope.

Out of compliance, complaint, investigation inspection : R380-80-5(10) Services and supervision to meet each clients needs

The provider was out of compliance with R380-80-5(10) for not providing services and supervision that is commensurate with the behaviors and needs of each client. During the inspection, interviews with staff and clients revealed chronic staffing shortages and a lack of qualified personnel equipped to manage aggressive client behaviors. Clients reported feeling unsafe, being unable to access emotional support, and engaging in physical confrontations with client peers and staff. Furthermore, the provider failed to maintain sufficient supervisory coverage, which routinely restricted clients from participating in outdoor activities, off-ground outings, and basic hygiene tasks such as showering.

Out of compliance, complaint, investigation inspection : R380-80-5(4) Provider shall protect clients from abuse, prevent abuse

The provider was out of compliance with R380-80-5(4) for failing to protect a client from harm and any action that may compromise the safety of the client through acts or omissions. During the inspection, investigative interviews revealed that a client had eloped from the facility. Upon return, the provider failed to conduct a search of the client who had concealed a box opener on their person and ultimately self harmed with it, cutting their arm and neck.

Out of compliance, complaint, investigation inspection : R380-80-5(3) Provider shall comply with policies and safe practices

The provider was out of compliance with R380-80-5(3) for failing to comply with applicable written policies and safe practices. During the inspection, the provider self-reported non-compliance to the OL investigator, acknowledging that staff failed to execute mandatory search procedures upon a client's return to the facility.

Out of compliance, complaint, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(e) for failing to ensure that each client has the right to be free from neglect. During the inspection, an investigative interview revealed that a client engaged in self-harm. She sustained deep arm lacerations but did not receive required medical intervention, specifically sutures, to properly treat and heal the wounds.

Out of compliance, complaint, investigation inspection : R380-80-5(7) Maintaining health and safety of clients

The provider was out of compliance with R380-80-5(7) for failing to maintain the health and safety of a client by allowing a client to attempt suicide. During the inspection, investigative interviews revealed that a client initiated a suicide attempt in a bathroom and lost consciousness. At the time of the incident, a single staff member was left alone in the hallway supervising eight other clients, creating a supervisory deficit that delayed intervention.

Out of compliance, complaint, investigation inspection : R380-80-5(4) Provider shall protect clients from abuse, prevent abuse

The provider was out of compliance with R380-80-5(4) for failing to protect a client from any action that may compromise their health and safety. During the inspection, investigative interviews revealed that a client had swallowed a battery. The provider did not seek any emergency medical treatment for the client, such as sending the client to the Emergency Room. The provider waited until 2 days after the event to monitor the client on-site via their mobile xray. This incident was not reported to the Office of Licensing.

Out of compliance, complaint, investigation inspection : R380-80-5(4) Provider shall protect clients from abuse, prevent abuse

The provider was out of compliance with R380-80-5(4) for failing to protect a client from any action that may compromise their health and safety. During the inspection, investigative interviews revealed that a client had swallowed a battery. The provider did not seek immediate medical attention or send the client to the Emergency Room. The provider waited before providing any treatment and after six days, the provider had the client monitored on-site via their mobile xray.

Out of compliance, complaint, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(c) for failing to ensure that each client has the right to be free from potential harm or acts of violence. During the inspection, video evidence and investigative interviews confirmed that five (5) clients attacked a peer in the cafeteria. Staff members failed to intervene effectively, separate the individuals, or prevent the victim from sustaining multiple facial punches, which resulted in a concussion, a black eye, and a laceration requiring medical adhesive.

Out of compliance, complaint, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(b) for failing to ensure that each client has the right to be treated with dignity and respect. During the inspection, investigative interviews with multiple clients revealed that a staff member had entered their bedrooms and woken them up by touching their face or leg, distributed shirtless photographs of himself with his personal phone number written on the back, and hid personalized notes tucked into the mattresses of several clients.

Out of compliance, complaint, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(b) for failing to ensure each client has the right to be treated with dignity and respect. During the inspection, investigative interviews with several clients disclosed a staff member making inappropriate sexual and homophobic remarks. This staff member has also shared details of her own personal trauma with clients. 26B-2-123(1)(a)-(b): Use of a cruel, severe, unusual, or unnecessary practice on a child — The provider was out of compliance with 26B-2-123(1)(a)(ix) for engaging in an unnecessary restraint and aggressive physical contact. During the inspection, investigative interviews and video evidence revealed an unnecessary and unjustified physical restraint of a client. The client verbally refused to go to her room and exhibited no physical aggression or safety risk prior to the restraint. Video footage showed a staff member pushing the client into a second staff member. The second staff member grabbed the client by the arms, took her to the floor, held her arms behind her back, and sat her between his legs. A third staff member laid on top of the client's legs. This position restricted her movement for over 15 minutes.

Out of compliance, complaint, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(e) for failing to ensure that each client has the right to be free from neglect. During the inspection, investigative interviews confirmed that a client required dental care to replace a missing cap but was prevented from attending a scheduled follow-up appointment one month later due to provider-reported "safety concerns." The provider was unable to verify if the appointment was rescheduled or whether the client received care. Consequently, three months have elapsed without the necessary treatment, leaving the client in pain and discomfort when chewing.

Out of compliance, complaint, investigation inspection : R380-80-5(7) Maintaining health and safety of clients

The provider was out of compliance with R380-80-5(7) for failing to maintain the health of clients. During the inspection, the investigator conducted a walkthrough of the facility which revealed that every bathroom in each cottage was unsanitary, with sticky surfaces, a strong odor of urine, and a deficit of essential supplies, specifically toilet paper and paper towels.

Out of compliance, complaint, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(d) for failing to ensure each client has the right to be free from discrimination. During the inspection, the investigator conducted a walkthrough of the facility observing extensive vulgar, racist, and discriminatory graffiti present on the walls, windows, and furniture within every dormitory unit.

Out of compliance, complaint, investigation inspection : R501-14-4(3)(a)-(c) Agency's roster and employee information current

The provider was out of compliance with R501-14-4(3)(b) by not checking the DACS background screening system roster at least monthly to verify employee information and the employment of the employees due for a renewal review. During the investigation inspection, eight (8) staff members were identified who did not pass a background screening and had access to clients and/or client records.

Out of compliance, complaint, investigation inspection : R501-14-5(2)(a)-(b) Application submitted within 2 weeks and applicant directly supervised

The provider was out of compliance with R501-14-5(2)(b)(i)(ii) by not ensuring each applicant is directly supervised until OBP issues a conditional or eligible clearance determination. During the investigation inspection, an audit identified 100 staff members whose background screening clearance determination status required each one to have direct, uninterrupted audio and visual supervision by a fully background cleared staff member at all times when accessing clients or client records. During on-site investigation inspections and throughout facility video coverage review, OL investigators directly observed multiple staff members from this audit list interacting with clients without the required supervision.

Out of compliance, complaint, investigation inspection : R501-14-5(2)(a)-(b) Application submitted within 2 weeks and applicant directly supervised

The provider was out of compliance with R501-14-5(2)(a) for not submitting a background check application for each applicant for an initial background check no later than two weeks from the date the applicant becomes associated with the licensee, certification, or contract. During the investigation inspection, the provider had not submitted applications for three (3) staff members who have worked for the provider for more than two weeks.

Out of compliance, investigation inspection : R380-80-6(1)(a)-(i) Client rights

The provider was out of compliance with R380-80-6(1)(c) by failing to keep a client free from acts of harm. During an investigation inspection, the investigator discovered that during a restraint on April 13, 2025, a staff member, through physical contact with the client, caused an injury to a client's face.

Out of compliance, investigation inspection : R380-80-5(3) Provider shall comply with policies and safe practices

The provider was out of compliance with R380-80-5(3) by not complying with applicable written policies and safe practices that address the appropriate treatment of clients. During the investigation inspection, it was determined a staff member did not implement the Handle With Care behavior management policy on which they were trained per the documentation provided. As a result of the failure to follow the policy, a client was injured.