Inspection Reports for
Utah State Developmental Center
895 North 900 East, American Fork, UT, 84003
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Renewal
Deficiencies: 4
Date: Oct 17, 2023
Visit Reason
A recertification inspection was conducted from 10/16/2023 to 10/17/2023 to survey the Utah State Developmental Center according to federal regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities.
Findings
Non-compliance was identified and deficiencies were cited related to client records, protection of clients' rights, active treatment, and individual program plans. Specific incidents involving client restraint and incomplete incident reporting were noted, along with failures to ensure clients' rights to communicate privately and receive continuous active treatment.
Deficiencies (4)
The facility did not maintain a recordkeeping system documenting clients' health care and protection of rights for 2 of 11 sampled clients.
The facility did not ensure clients had the opportunity to communicate, associate, and meet privately for 2 of 10 sampled clients.
One client did not receive a continuous active treatment program including aggressive, consistent implementation of specialized training and health services.
Individual program plans were not completed or updated timely for sampled clients, including assessments and behavioral goals.
Report Facts
Incident report completion: 2
Sampled clients: 11
Sampled clients: 10
Incident duration: 1.3
Medication administration frequency: 18
Data collection frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jared Brown | Lead Licensor | Approved the Plan of Correction on 12/11/2023. |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Oct 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration, program implementation, and other regulatory compliance issues at the Utah State Developmental Center.
Complaint Details
The visit was complaint-related focusing on medication administration errors, program implementation failures, client behavior management, and life safety code compliance. Specific complaints included improper medication handling, failure to follow treatment schedules, and unsafe environmental conditions.
Findings
The facility was found deficient in multiple areas including medication administration errors, failure to implement active treatment schedules, inadequate program documentation, improper management of client behavior, and deficiencies in life safety systems such as sprinkler maintenance and egress door locking arrangements.
Deficiencies (12)
W249 - Medication administration was observed to be improperly handled for Client 13, including mixing medications and failure to follow medication program steps.
W250 - The facility failed to develop an active treatment schedule outlining the current active treatment program readily available for review by relevant staff.
W252 - Data relative to accomplishment of client individual program plan objectives was not documented in measurable terms for Client 2's medication program.
W257 - The individual program plan was not reviewed at least by the qualified intellectual disability professional and revised as necessary for Client 8.
W262 - The committee did not review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs involving risks to client protection and rights for Clients 6 and 11.
W286 - Techniques to manage inappropriate client behavior were used for disciplinary purposes for Client 6, violating regulatory standards.
W292 - Placement of Client 1 in a time-out room exceeded the one-hour maximum allowed.
W369 - The system for drug administration failed to assure that all medications were administered without error for Client 14.
K353 - The facility did not maintain the fire sprinkler system in accordance with NFPA 25 and NFPA 101 standards, lacking documentation of fire riser gauge calibration within the last 5 years.
K511 - Electrical outlets in the nurse's station medication room and the WC 129 nurse's station medication room sink were not GFCI protected as required by NFPA 101.
K222 - Egress doors were not maintained with required locking arrangements, including delayed-egress locking systems, preventing proper emergency exit.
W455 - The facility lacked an active infection control program for prevention, control, and investigation of infection and communicable diseases.
Report Facts
Medication administrations sampled: 9
Medication administrations sampled: 11
Medication administrations total: 18
Date of inspection: Oct 17, 2023
Completion date for plans of correction: Dec 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 14 | Observed medication administration and acknowledged failure to run Client 13's medication program | |
| Employee 7 | Observed medication administration for Client 2 and acknowledged medication goal not run at every opportunity | |
| Employee 15 | Interviewed about Client 2's medication program goals and medication administration | |
| Employee 1 | Interviewed about Client 3's schedule and activities | |
| Employee 3 | Interviewed about Client 2's daily schedule and work assignments | |
| Employee 4 | Interviewed about Client 2's daily schedule and PM shift work | |
| Employee 6 | Interviewed about infection control policy and PPE availability | |
| Employee 2 | Interviewed about Client 14's medication administration | |
| Employee 5 | Observed preparing breakfast for Client 14 | |
| Employee 10 | Observed during restraint incident with Client 1 | |
| Employee 11 | Involved in restraint incident with Client 1 | |
| QIDP 1 | Qualified Intellectual Disability Professional | Interviewed about active treatment program and self-medication program compliance |
| QIDP 2 | Qualified Intellectual Disability Professional | Interviewed about Client 3's schedule and active treatment program |
| QIDP 3 | Qualified Intellectual Disability Professional | Interviewed about Client 2's daily schedule and medication program |
| QIDP 4 | Qualified Intellectual Disability Professional | Interviewed about Client 8's self-medication program |
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