Inspection Reports for
St. Anne’s Center dba Lantern House (RS)
269 W 33rd St., Ogden, UT, 84401
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
38 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
381% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Census: 333
Capacity: 333
Deficiencies: 16
Date: Jan 28, 2025
Visit Reason
The inspection was an announced annual licensing inspection to assess compliance with licensing rules and regulations for the Lantern House facility.
Findings
The inspection identified multiple noncompliance issues across various regulatory areas including physical facility maintenance, program policies, client records, staffing, and specialized services. Several deficiencies were corrected during the inspection, while others require follow-up.
Deficiencies (16)
Program Physical Facilities and Safety: Several units had missing soap and paper towels, holes in walls, HVAC issues causing cold temperatures, dirty bathrooms, and missing outlet covers.
New and Renewal Licensing Procedures: The provider accepted fees and provided client services before license approval, violating licensing rules.
Inspection and Investigation Process: The licensee failed to submit critical incident reports within required timeframes and notify guardians appropriately.
Program Policies, Procedures, and Safe Practices: The licensee did not comply with safe practices ensuring client health and safety and failed to submit required policy changes for approval.
Residential Programs Additional Safe Practices: The licensee failed to ensure compliance with medication management, animal care, infectious disease separation, and transport staff-to-client ratios.
Program Administrative and Direct Service Requirements: The licensee did not clearly identify services, post required notices, maintain required permits, or provide organizational documentation as required.
Program Physical Facilities and Safety: The facility failed to maintain cleanliness, proper supplies, and safe conditions in bathrooms and other areas.
Residential Program Additional Facilities and Safety Requirements: The licensee failed to maintain medication storage, first aid kits, and accommodations for clients with disabilities.
Residential Program Additional Program Intake and Discharge Requirements: The licensee failed to complete intake assessments and discharge plans as required.
Program Clinical Services: Clinical services were not required for this license type but noted as not applicable.
Program Staffing: The licensee failed to ensure adequate staffing, qualified management, background clearances, and tuberculosis screening for staff.
Personnel Training Requirements: Staff did not receive all required pre-service and annual training topics before working unsupervised.
Residential Support Programs - Administration, Staffing, Physical Facility: Multiple noncompliances were noted including failure to provide 24-hour supervision, safe practices, background checks, and bathroom ratios.
Specialized Services for Programs Serving Clients With Substance Use Disorders and Domestic Violence Shelters: Noncompliance with documentation, client supervision, action plans, and referrals was noted.
Specialized Services for Emergency Homeless Shelters: The licensee failed to maintain required staffing ratios, client agreements, and documentation for client information and service plans.
Specialized Services for Programs Serving Clients of the Division of Services for People with Disabilities and Receiving Centers: Noncompliance with attestation forms, documentation, and consumer agreements was noted.
Report Facts
Number of Present Residents/Clients: 333
Approved Capacity: 333
Number of Non Compliant Items: 1
Inspection Report
Renewal
Capacity: 330
Deficiencies: 24
Date: Feb 5, 2024
Visit Reason
The inspection was an announced renewal licensing inspection conducted to verify compliance with licensing rules and regulations for Lantern House.
Findings
The inspection identified multiple noncompliance issues across various regulatory areas including licensing procedures, program policies, medication management, client records, staffing, training, physical facilities, food service, and specialized services for emergency homeless shelters. Several deficiencies were noted as not corrected during the inspection.
Deficiencies (24)
R380-600-3(1) An applicant or provider may not accept any fee, enter into any agreement, or provide client service until license approval by the office.
R380-600-3(2) Providers must comply with all applicable administrative rules, statutes, zoning, fire, safety, sanitation, building, and licensing laws.
R380-600-3(3) Providers must permit immediate, unrestricted access to licensing office for sites, client records, and staff.
R380-600-6(2) Providers may not deviate from administrative rules without written approval from the office director or designee.
R501-1-4(2) Licensee must develop and comply with safe practices ensuring client health, safety, and program compliance with administrative rules.
R501-1-5(1) Licensee managing medications must ensure staff and clients are informed of medication responsibilities and staff are trained in administration and error reporting.
R501-1-7(1) Licensee must ensure staff shift lists are current, at least two on-duty staff are present at all times, and provide separate space for clients with infectious disease symptoms.
R501-1-9(1) Licensee must provide designated space for records, separate bedrooms and bathrooms for live-in staff, and ensure client privacy and hygiene supplies.
R501-1-12(4) Licensee must ensure client, parent, or guardian signs and receives copies of eligibility, fee agreement, and consent for treatment documents.
R501-1-12(5) Licensee must ensure discharge plans identify reason, aftercare, summary of services, and progress evaluation.
R501-1-13(1) Licensee must complete intake assessments within seven days including gender identity, cultural background, medical history, and suicide risk screening.
R501-1-15(10) Two staff were missing applicable qualifications, experience, certification, or license documentation.
R501-1-16(1) Three staff were missing first aid training; training topics d,g,j,k need to be added for all staff.
R501-1-16(2) Annual training topics b,f,h,i,j,o need to be added; ensure all training requirements are met for all staff.
R501-1-12(4) Three clients were missing suicide risk screeners; provider plans to add documentation to client intake forms.
R501-22-3(2) Licensee must obtain appropriate categorical department license for treatment.
R501-22-3(5) Licensee must provide evidence of ongoing coordination with local health authorities regarding communicable diseases.
R501-22-5(1) Licensee must provide at least one bathroom for every ten clients.
R501-22-5(3) Emergency homeless shelter may exceed bathroom ratio if approved and privacy and accessibility are ensured.
R501-22-5(14) Licensee must develop safe practices to manage emergency overflow during dangerous weather conditions.
R501-22-6(2) Licensee must provide evidence of ongoing coordination with local health authorities for communicable diseases.
R501-22-8(1) Emergency shelter licensee must prioritize safety and emphasize transitioning to permanent housing.
R501-22-8(2) Emergency homeless shelter must maintain minimum staffing ratio of one staff per 40 clients during weekday daytime hours.
R501-22-8(5) Licensee must maintain client information including demographics, service plans, and health needs.
Report Facts
Number of Non Compliant Items: 4
Total Capacity: 330
Missing Suicide Risk Screeners: 3
Staff Missing Qualifications: 2
Staff Missing First Aid Training: 3
Inspection Report
Renewal
Capacity: 333
Deficiencies: 74
Date: Feb 16, 2023
Visit Reason
Annual renewal inspection of Lantern House, a congregate care facility, to assess compliance with licensing and regulatory requirements.
Findings
The inspection identified multiple areas of noncompliance across various program requirements including licensing procedures, program administration, physical facilities, staffing, and specialized services. Some deficiencies were noted in fire drill documentation, medication storage, and staff training.
Deficiencies (74)
R501-1-14(6). Direct care staff are not trained in first aid and CPR within six months of hire.
R501-1-15(1). The appearance and cleanliness of the building and grounds are not maintained free from health and fire hazards.
R501-1-15(2). Appliances, plumbing, electrical, HVAC, and furnishings are not maintained in operating order and in a clean and safe condition.
R501-1-15(4). Fire drills in non-outpatient programs are not conducted and documented at least quarterly; the 4th quarter fire drill is missing.
R501-1-15(5). A 911 recognizable phone is not always on-site with clients.
R501-1-15(6). Bathroom facilities for staff and clients do not allow for individual privacy and reasonable accommodation based on gender identity.
R501-1-15(7). Bathrooms are not properly equipped with toilet paper, paper towels or a dryer, and soap.
R501-1-15(8). Bathrooms are not ventilated by mechanical means or equipped with a window that opens.
R501-1-15(9). Medications and potentially hazardous items on-site are not maintained lawfully and responsibly with consideration of safety and risk level.
R501-1-15(10). Non-prescription medications are not stored in original manufacturer's packaging with directions and warnings.
R501-1-15(11). Prescription medications are not stored in original pharmacy packaging or bubble packs with labels and warnings.
R501-1-16(1). There is no designated space available for records, administrative work, and confidential phone calls for clients.
R501-1-24. The program has not developed, implemented, and complied with policies and procedures sufficient to ensure client health and safety and meet client needs.
R501-1-25(1). Residential programs that provide meals for clients do not have and follow a food service policy.
R501-1-25(2). Residential programs managing, storing, or administering client medications do not have and follow a medication management policy.
R501-1-25(3). Residential programs lack a policy to train staff to identify and address critical risks including violence, suicide, and mental health concerns.
R501-1-25(4). Residential programs lack a policy regarding care, vaccination, licensure, and maintenance of any animals on-site.
R501-1-25(5). Residential programs lack a client belongings policy addressing inventory, storage, return, and replacement of client belongings.
R501-1-25(6). A program managing funds for client allowances does not document each expense.
R501-1-25(7). Residential programs do not develop and follow a policy for providing separate space for sick clients.
R501-1-26. The program uses behavior management techniques, restraints, or curriculum not approved by the office, including prohibited practices such as inducing pain, peer restraints, and punishment intended to frighten or humiliate.
R501-22-3(2). The residential support program offering treatment has not obtained the appropriate categorical department license for that treatment.
R501-22-3(4). The residential support requires treatment as a condition of admission.
R501-22-4(1). The residential support program serving adults as an emergency homeless shelter or domestic violence shelter does not provide 24-hour supervision.
R501-22-4(2). The program lacks a policy and procedure identifying situations requiring medical attention and how client medical needs will be met.
R501-22-4(3). The residential support program does not provide screening, training, and evaluation for each student or volunteer accepted.
R501-22-4(4). Volunteers providing care without paid staff present lack direct communication access to designated staff and cleared background screening prior to unsupervised client access.
R501-22-4(5). Volunteers are not informed verbally and in writing of program objectives and scope of service.
R501-22-4(6). The emergency homeless shelter is unable to provide required client information or lacks documented reasons for missing information.
R501-22-5(1). The residential support program does not have at least one bathroom for every ten clients.
R501-22-5(2). The domestic violence shelter and emergency homeless shelter do not maintain client privacy where bathrooms are shared.
R501-22-5(3). The emergency homeless shelter exceeds bathroom ratio requirements without approval or fails to meet inspection, cleaning, and restocking standards.
R501-22-5(4). The emergency homeless setting lacks a policy to manage emergency overflow during extreme weather conditions.
R501-22-5(5). The residential support program lacks a policy and procedure to allow and encourage clients to have clean linen at least weekly.
R501-22-5(6). The emergency homeless program does not have portable beds, cots, or mats to accommodate fluctuating client volume.
R501-22-5(7). The residential support program does not provide clean bedding to each client as needed or launder bedding at least weekly.
R501-22-5(8). Family sharing bedroom space lacks program rules as described in the rule and dormitory settings.
R501-22-5(9). Bedroom standards for domestic violence shelters, family support centers, temporary homeless youth shelters, emergency homeless family shelters, and children's shelters are not met.
R501-22-5(10). Temporary youth shelter does not ensure children with their own children have at least 40 square feet per person in a separately enclosed bedroom.
R501-22-5(11). Emergency homeless shelter, temporary homeless youth shelter, and receiving center do not meet standards for dormitory style bedrooms or lack policies to manage overflow.
R501-22-5(12). The program lacks policies and procedures regarding rules for family or mixed gender sharing dormitory space, securing personal belongings, supervision of children, conflict resolution, disruptive behavior, housekeeping, schedules, prohibited items, and search policy.
R501-22-5(13). The program lacks a policy to assist clients who cannot provide laundry supplies or locate laundromats.
R501-22-6(1). The program admits individuals currently experiencing convulsions, shock, delirium tremens, unconsciousness, or coma.
R501-22-6(2). The residential support program lacks evidence of ongoing coordination with local health authorities regarding communicable diseases.
R501-22-6(3). Staff are not informed regarding communicable diseases, signs and symptoms, outbreak response, and tuberculosis screening.
R501-22-6(4). The program does not complete the National Survey of Substance Abuse Treatment annually if licensed for substance abuse treatment.
R501-22-7(2). The residential support program does not provide clean and safe age-appropriate toys for children.
R501-22-7(3). The residential support program does not provide an outdoor play area enclosed with a five-foot safety fence or as required by local ordinances.
R501-22-7(4). Persons other than custodial parents, legal guardians, or designated persons in writing are allowed to remove children from the program.
R501-22-7(5). The residential support program lacks adequate staff to supervise children or monitor parents supervising their children.
R501-22-7(6). The program does not comply with the Interstate Compact on the Placement of Children including disruption plan adherence.
R501-22-8(1). The domestic violence shelter does not provide shelter rules, reasons for termination, and confidentiality issues verbally and in writing.
R501-22-8(2). The parent is not responsible for supervising their child or arranging appropriate child-care services when away from the shelter.
R501-22-8(3). The domestic violence shelter action plan lacks review and discussion of victim danger, safety plans, protective orders, and supportive services.
R501-22-8(4). The program does not facilitate connecting services to identified resources.
R501-22-8(5). Appropriate referrals for victim treatment, psychiatric consultation, drug and alcohol treatment, or allied services are not made or documented.
R501-22-8(6). Domestic violence shelter staff completing action plans are not supervised by experienced and trained domestic violence providers.
R501-22-9(1). The temporary homeless youth shelter does not provide a staff ratio of at least one direct care staff for every ten children.
R501-22-9(2). Individuals admitted are not all under the age of 18.
R501-22-9(3). Children may be admitted without their own biological children.
R501-22-9(4). The temporary homeless youth shelter does not place individuals older than 18 but younger than 21 in age and gender appropriate sleeping quarters or lacks assessments for imminent risk.
R501-22-9(5). The temporary youth homeless shelter does not document individualized assessments of risk of harm and justification for each client admitted.
R501-22-9(6). The temporary homeless youth shelter does not comply with mandatory notifications for harboring a runaway child.
R501-22-9(7). The temporary homeless youth shelter does not coordinate educational requirements for each individual.
R501-22-9(8). The temporary homeless youth shelter does not coordinate and transition clients to more appropriate settings when unable to remain in the youth setting.
R501-22-10(1). The emergency shelter does not prioritize safety or emphasize transitioning to permanent housing.
R501-22-10(2). The emergency homeless shelter does not ensure minimum staffing ratios of two direct care staff or one staff per 40 clients during weekday daytime hours.
R501-22-10(3). The emergency homeless shelter lacks documented chain of command, surveillance cameras, emergency radios, or backup support for emergency deviations in staffing.
R501-22-10(4). The emergency homeless shelter does not require adult residents to sign agreements outlining visitor policies and voluntary participation in services.
R501-22-11(1). Programs serving HCBS waiver clients do not complete or adhere to residential attestation agreements and self-assessment surveys.
R501-22-11(2). Copies of residential attestation agreements and self-assessment surveys are not located or updated in program documentation.
R501-22-12(3). Receiving centers lack policies and consumer agreements on population separation and interaction circumstances.
R501-22-12(4). Receiving centers lack individualized clinical documentation for stays longer than 30 days outlining ongoing need and anticipated time frame.
R501-22-12(5). Placements in receiving centers are not voluntary alternatives to more restrictive placements and may mandate treatment as a condition of residence.
Report Facts
Approved Capacity: 333
Number of Non Compliant Items: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Summer Rohwer | Individual Informed of this Inspection | Named as the individual informed of the inspection and signer of the checklist |
| Shelisa York | Licensor | Licensor conducting the inspection |
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