{"idNumber":"F22-95788","name":"Metro Treatment of Utah, LP dba New Season 410 - 411 Treatment Center","address":{"suggestedAddress":null,"id":null,"addressOne":"763 W. 700 S.","addressTwo":"Suite B","city":"Woods Cross","state":"UT","zipCode":"84087","county":null,"addressString":" 763 W. 700 S. Suite B Woods Cross, UT 84087","valid":true},"phone":"8012922318","type":null,"licenseType":"Outpatient Treatment","capacity":0,"underAgeTwoCapacity":null,"initialRegulationDate":"2022-09-01","expirationDate":"2026-10-31","conditional":false,"condExpirationDate":null,"status":"REGULATED","occQiReq":null,"licenseTypes":[{"name":"Outpatient Treatment","licenseExpirationDate":"2026-10-31","status":null,"totalCapacity":0,"underAgeTwoCapacity":null}],"inspections":[{"id":null,"inspectionDate":"2025-12-02","inspectionTypes":"Follow-Up Inspection, Non On-Site Inspection","checklistIds":[],"findings":[],"underAppeal":false},{"id":null,"inspectionDate":"2025-11-04","inspectionTypes":"Follow-Up, Non On-Site, Additional","checklistIds":[],"findings":[{"ruleId":26502,"ruleNumber":"R501-21-5(2)(a)-(b)","ruleDescription":"Counselor to client ratio and practitioner visit requirements","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-12-02","cmpAmount":100.0,"warnCmpAmount":100.0,"correctionAction":"On December 2, 2025 the licensor verified that the provider had an active variance for counselor to client ratios, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-21-5(2)(a) by providing medication for opioid use disorder and not maintaining a program-wide counselor to client ratio of 1:65. During the inspection, the provider had a counselor to client ratio of 2:198. This is a repeat non compliance as noted on 6/5/2025 and 7/31/2025.","underAppeal":false}],"underAppeal":false},{"id":null,"inspectionDate":"2025-09-04","inspectionTypes":"Follow-Up Inspection, Non On-Site Inspection","checklistIds":[],"findings":[{"ruleId":25678,"ruleNumber":"R501-1-12(4)(a)-(c)","ruleDescription":"Required signed agreements","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":200.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had complete client rights and licensing contact information signed by the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-12(4)(c)(v, vi) by not maintaining complete signed consent for treatment forms as client records. At the time of the inspection, 3 client records were missing the Department of Health and Human Services (DHHS) client rights and DHHS Office of Licensing contact information on signed agreements. This is a repeat noncompliance as noted on 6/14/2023, 6/25/2024, 8/12/2024, 6/5/2025, 7/31/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider has treatment plans that are updated and regularly reviewed, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(a)(i-iii) by not having a clinical director ensuring that assessment, treatment, and service planning practices are regularly reviewed and updated; individualized; and designed to involve the participation of each client. At the time of the inspection, 1 client's treatment plan had not been updated since October 2024, was not individualized to the client, and did not involve client participation in the creation of the treatment plan. This is a repeat noncompliance as noted on 6/5/2025 and 7/31/2025.","underAppeal":false},{"ruleId":30353,"ruleNumber":"R501-21-5(4)(a)-(c)","ruleDescription":"Opioid treatment program requirements","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had a licensed registered nurse start on 11/3/2025 meeting the requirements, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-21-5(4)(c) by not ensuring there was one qualified provider to dispense or administer medications for every 150 methadone clients dosing on an average daily basis. At the time of the inspection, the provider was administering and dispensing methadone and had unqualified providers dispensing and administering medications, and was serving 189 clients. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25695,"ruleNumber":"R501-1-11(1)(a)-(o)","ruleDescription":"Required client information","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":200.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider collected gender identity for all clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-11(1)(a) by not maintaining all required client information. At the time of the inspection, 3 client files did not contain identified gender. This is a repeat noncompliance as noted on 6/14/2023, 6/25/2024, 8/12/2024, 6/5/2025, and 7/31/2025.","underAppeal":false},{"ruleId":26012,"ruleNumber":"R501-1-12(1)(a)-(d)","ruleDescription":"Required Intake screening assessment","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed an intake screener on the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-12(1)(a-d) by not completing an intake screening for clients prior to accepting them into the program. At the time of the inspection, 3 client that were currently receiving services did not have intake screeners to verify they met criteria to be served under this license completed. This is a repeat noncompliance as noted on 6/5/2025 and 7/31/2025.","underAppeal":false},{"ruleId":27119,"ruleNumber":"R501-21-5(10)(a)-(e)","ruleDescription":"Requirements for providers offering services to justice-involved clients","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed the application and payment to begin using the RANT criminogenic risk assessment tool as evidenced by email exchange shown to the licensor, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-21-5(10)(b) by not maintaining a validated criminogenic screen or risk assessment for each justice-involved client. At the time of the inspection, the provider did not possess or use a validated risk assessment tool and was offering services to justice-involved clients. This is a repeat noncompliance as noted on 6/5/2025 and 7/31/2025.","underAppeal":false},{"ruleId":25716,"ruleNumber":"R501-1-16(2)(a)-(q)","ruleDescription":"Program policy and training","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":200.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed all training requirements with the staff named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-16(2)(b, f) by not having all annual training requirements completed for staff. At the time of the inspection, 3 staff files did not contain documentation of annual training completion on general provisions rules, outpatient treatment licensing rules, and the program plan for the prevention or control of infectious and communicable disease to include coordination with and following any guidance of the state or local health authorities, Center for Disease Control, and the department. This was a repeat noncompliance as noted on 6/14/2023, 6/25/2024, 8/12/2024, 6/5/2025, and 7/31/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had individualized treatment plans for the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(d) by not ensuring discharge goals are identified in the initial treatment plan and treatment goals are structured around the identified discharge goals and objectives. At the time of the inspection, 1 client treatment plan did not have a discharge goal identified or subsequent treatment goals and objectives structured around the discharge goal. This is a repeat noncompliance as noted on 6/5/2025 and 7/31/2025.","underAppeal":false}],"underAppeal":false},{"id":null,"inspectionDate":"2025-07-31","inspectionTypes":"Follow-Up Inspection, Non On-Site Inspection","checklistIds":[],"findings":[{"ruleId":25678,"ruleNumber":"R501-1-12(4)(a)-(c)","ruleDescription":"Required signed agreements","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":200.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had complete client rights and licensing contact information signed by the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-12(4)(c)(v, vi) by not maintaining complete signed consent for treatment forms as client records. During the inspection, 3 client records were missing the Department of Health and Human Services (DHHS) client rights and DHHS Office of Licensing contact information on signed agreements. This is a repeat noncompliance as noted on 6/14/2023, 6/25/2024, 8/12/2024, and 6/5/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-09-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On September 4, 2025 the licensor verified that the provider was in compliance with (c) having signed treatment plans as they submitted a signed treatment plan for the client named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(e) by not ensuring that each client identified for treatment receives individual treatment at least weekly. During the inspection, 3 clients' files did not contain proof that they had been receiving weekly individual therapy. This is a repeat non compliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-09-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On September 4, 2025 the licensor verified that the provider was in compliance with (f) by the provider stating they will document missed appointments and will ensure compliance by conducting training and routine audits of clinical documentation to ensure continued compliance, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(f) by not ensuring that any missing individual weekly treatment is justified, approved, and documented by the clinical director. During the inspection, 3 clients were not attending weekly therapy and the provider had no approved documentation as to why individual treatment was missed. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-09-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On September 4, 2025 the licensor verified that the provider was in compliance with (e) by the provider stating they will ensure treatment is conducted in accordance with the dosage noted in the treatment plans and will ensure compliance by conducting training and routine audits of clinical documentation to ensure continued compliance, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(a)(i-iii) by not having a clinical director ensuring that assessment, treatment, and service planning practices are regularly reviewed and updated; individualized; and designed to involve the participation of each client. During the inspection, 1 client's treatment plan had not been updated since October 2024, was not individualized to the client, and did not involve client participation in the creation of the treatment plan. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider has treatment plans that are updated and regularly reviewed, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(c) by not ensuring client treatment plans are developed and signed by a licensed clinical professional within 30 days of admission. During the inspection, 2 clients that had been admitted for longer than 30 days did not have treatment plans developed. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25712,"ruleNumber":"R501-1-14(1)(a)-(f)","ruleDescription":"Clinical director responsibilities","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had individualized treatment plans for the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-14(1)(d) by not ensuring discharge goals are identified in the initial treatment plan and treatment goals are structured around the identified discharge goals and objectives. During the inspection, 1 client treatment plan did not have a discharge goal identified or subsequent treatment goals structured around the discharge goal. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":30353,"ruleNumber":"R501-21-5(4)(a)-(c)","ruleDescription":"Opioid treatment program requirements","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had a licensed registered nurse start on 11/3/2025 meeting the requirements, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-21-5(4)(c) by not ensuring there was one qualified provider to dispense or administer medications for every 150 methadone clients dosing on an average daily basis. During the inspection, the provider had unqualified licensed practical nurses (LPN) dispensing and administering medications, and was serving 189 clients. This is a repeat non compliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25695,"ruleNumber":"R501-1-11(1)(a)-(o)","ruleDescription":"Required client information","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":200.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider collected gender identity for all clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-11(1)(a) by not maintaining all required client information. During the inspection, 3 client files did not contain identified gender. This is a repeat noncompliance as noted on 6/14/2023, 6/25/2024, 8/12/2024, 6/5/2025.","underAppeal":false},{"ruleId":26012,"ruleNumber":"R501-1-12(1)(a)-(d)","ruleDescription":"Required Intake screening assessment","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed an intake screener on the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-12(1)(a-d) by not completing an intake screening for clients prior to accepting them into the program. During the inspection, 3 client that were currently receiving services did not have intake screeners to verify they met criteria to be served under this license completed. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":28972,"ruleNumber":"R501-1-6(9)","ruleDescription":"Clinical and medical staff are licensed","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-09-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On September 4, 2025 the licensor verified that the provider was in compliance by ensuring the nurse noted in the inspection report now has an active interstate compact license with the Division of Occupational and Professional Licensing, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-6(9) by not ensuring that all clinical and medical staff are licensed as described in Title 58, Occupations and Professions. During the inspection, 1 nurse was not licensed to operate as a nurse within the state of Utah, and was not licensed or acknowledged by the Utah Division of Professional Licensing as being approved to practice as a nurse in Utah via an interstate compact. This is a repeat noncompliance as noted on 06/05/2025.","underAppeal":false},{"ruleId":27119,"ruleNumber":"R501-21-5(10)(a)-(e)","ruleDescription":"Requirements for providers offering services to justice-involved clients","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed the application and payment to begin using the RANT criminogenic risk assessment tool as evidenced by email exchange shown to the licensor, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-21-5(10)(b) by not maintaining a validated criminogenic screen or risk assessment for each justice-involved client. During the inspection, the provider did not possess or use a validated risk assessment tool and was offering services to justice-involved clients. This is a repeat noncompliance as noted on 6/5/2025.","underAppeal":false},{"ruleId":25716,"ruleNumber":"R501-1-16(2)(a)-(q)","ruleDescription":"Program policy and training","complaintDates":null,"findingCategory":"REPEAT_CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":200.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed all training requirements with the staff named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-16(2)(b, f) by not having all annual training requirements completed for staff. During the inspection, 3 staff files did not contain documentation of annual training completion on general provisions rules, outpatient treatment licensing rules, and the program plan for the prevention or control of infectious and communicable disease to include coordination with and following any guidance of the state or local health authorities, Center for Disease Control, and the department. This was a repeat noncompliance as noted on 6/14/2023, 6/25/2024, 8/12/2024, and 6/5/2025.","underAppeal":false},{"ruleId":25715,"ruleNumber":"R501-1-16(1)(a)-(u)","ruleDescription":"Pre-service training requirements","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-09-04","cmpAmount":100.0,"warnCmpAmount":100.0,"correctionAction":"On September 4, 2025 the licensor verified that the provider was in compliance with preservice training requirements by submitting staff-signed attestation forms that each required training has been completed, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-16(1)(d, e, g, m, r, s, t) by not having all pre-service training requirements completed for staff within 30 days of hire and before being left unsupervised. During the inspection, 2 staff files did not have documentation of completed training on client eligibility, emphasizing the behaviors and circumstances the program can safely manage; staff involvement and responsibility in the intake, discharge, and unplanned discharge processes; non-discrimination policy that includes a prohibition of abuse, discrimination, and harassment based on sex, gender identity, or sexual orientation; appropriate searches; appropriate and inappropriate behaviors of clients; and appropriate and inappropriate staff responses to client behaviors. This is a repeat noncompliance as noted on 6/25/2024, 8/12/2024, and 6/5/2025.","underAppeal":false}],"underAppeal":false},{"id":null,"inspectionDate":"2025-06-05","inspectionTypes":"Announced, Annual Inspection","checklistIds":[657016],"findings":[{"ruleId":25678,"ruleNumber":"R501-1-12(4)(a)-(c)","ruleDescription":"Required signed agreements","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":100.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider had complete client rights and licensing contact information signed by the clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-12(4)(c)(v, vi) by not maintaining complete signed consent for treatment forms as client records. During the inspection, 3 client records were missing the Department of Health and Human Services (DHHS) client rights and DHHS Office of Licensing contact information on signed agreements. This was a repeat noncompliance as noted on 6/14/2023, 6/25/2024, and 8/12/2024.","underAppeal":false},{"ruleId":25695,"ruleNumber":"R501-1-11(1)(a)-(o)","ruleDescription":"Required client information","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":100.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider collected gender identity for all clients named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-11(1)(a) by not maintaining all required client information. During the inspection, 3 client files did not contain identified gender. This was a repeat noncompliance as noted on 6/14/2023, 6/25/2024, and 8/12/2024.","underAppeal":false},{"ruleId":25716,"ruleNumber":"R501-1-16(2)(a)-(q)","ruleDescription":"Program policy and training","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-11-04","cmpAmount":100.0,"warnCmpAmount":100.0,"correctionAction":"On November 4, 2025 the licensor verified that the provider completed all training requirements with the staff named in the inspection report, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-16(2)(b, f) by not having all annual training requirements completed for staff. During the inspection, 3 staff files did not contain documentation of annual training completion on general provisions rules, outpatient treatment licensing rules, and the program plan for the prevention or control of infectious and communicable disease to include coordination with and following any guidance of the state or local health authorities, Center for Disease Control, and the department. This was a repeat noncompliance as noted on 6/14/2023, 6/25/2024, and 8/12/2024.","underAppeal":false},{"ruleId":25715,"ruleNumber":"R501-1-16(1)(a)-(u)","ruleDescription":"Pre-service training requirements","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2025-09-04","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On September 4, 2025 the licensor verified that the provider was in compliance with preservice training requirements by submitting staff-signed attestation forms that each required training has been completed, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with R501-1-16(1)(d, e, g, m, r, s, t) by not having all pre-service training requirements completed for staff within 30 days of hire and before being left unsupervised. During the inspection, 2 staff files did not have documentation of completed training on client eligibility, emphasizing the behaviors and circumstances the program can safely manage; staff involvement and responsibility in the intake, discharge, and unplanned discharge processes; non-discrimination policy that includes a prohibition of abuse, discrimination, and harassment based on sex, gender identity, or sexual orientation; appropriate searches; appropriate and inappropriate behaviors of clients; and appropriate and inappropriate staff responses to client behaviors. This was a repeat noncompliance as noted on 6/25/2024 and 8/12/2024.","underAppeal":false}],"underAppeal":false},{"id":null,"inspectionDate":"2024-11-21","inspectionTypes":"Investigation Inspection","checklistIds":[],"findings":[],"underAppeal":false},{"id":null,"inspectionDate":"2024-08-27","inspectionTypes":"Non On-Site Inspection","checklistIds":[],"findings":[],"underAppeal":false},{"id":null,"inspectionDate":"2024-08-12","inspectionTypes":"Non On-Site Inspection","checklistIds":[],"findings":[{"ruleId":25695,"ruleNumber":"R501-1-11(1)(a)-(o)","ruleDescription":"Required client information","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2024-08-27","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On 8/27/2024 the licensor verified that the provider had complete client information including identified gender, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with this rule by not maintaining complete client information. During the inspection, client information did not include identified gender options aside from male or female. This was a repeat rule noncompliance.","underAppeal":false},{"ruleId":25678,"ruleNumber":"R501-1-12(4)(a)-(c)","ruleDescription":"Required signed agreements","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2024-08-27","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On 8/27/2024 the licensor verified that the provider had a complete signed consent for treatment including DHHS client rights and licensing contact information, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with this rule by not having a complete signed consent for treatment. During the inspection, the licensor saw that all client files were missing Department of Health and Human Services (DHHS) client rights and were also missing DHHS Office of Licensing contact information on signed agreements. This was a repeat rule noncompliance.","underAppeal":false},{"ruleId":25716,"ruleNumber":"R501-1-16(2)(a)-(q)","ruleDescription":"Program policy and training","complaintDates":null,"findingCategory":"CITED","noncomplianceLevel":"Low","correctionVerification":{"key":"VERIFIED","value":"Correction Verified","active":null},"correctionDate":"2024-08-27","cmpAmount":null,"warnCmpAmount":100.0,"correctionAction":"On 8/27/2024 the licensor verified that the provider had all staff trained on all requirements, as stated in rule.","appealDate":null,"declarativeStatement":"The provider was out of compliance with this rule by not ensuring all staff have completed all annual training requirements. During the inspection, all employees were missing annual training on program policies, procedures and safe practices as outlined in Section R501-1-4; general provisions and applicable categorical licensing rule; client eligibility, as outlined in Subsection R501-1-6(1)(e), emphasizing the behaviors and circumstances the program can safely manage; staff involvement and responsibility in the intake, discharge, and unplanned discharge processes; provider code of conduct as outlined in Rule R380-80; program plan for the prevention or control of infectious and communicable disease to include coordination with and following any guidance of the state or local health authorities, Center for Disease Control, and the department; emergency procedures to instruct staff how to address incident reporting, continuity of care, transport, relocation, and client health and safety during natural disasters, extreme weather events, fire, utility or structural failures, or other unexpected disruptions to the program service; program rules regarding firearms that does not conflict with constitutional or statutory rights regarding concealed weapons permits as described in Title 53, Chapter 5, Part 7, Concealed Firearms Act; smoking rules in accordance with Title 26B, Chapter 7, Part 5, Regulation of Smoking, Tobacco Products, and Nicotine Products; how to manage clients who screen with elevated suicide risk levels; general incident reporting; prevention, signs, and symptoms of abuse and neglect, including sexual abuse, and legal reporting requirements. This was a repeat rule noncompliance.","underAppeal":false}],"underAppeal":false},{"id":null,"inspectionDate":"2024-06-25","inspectionTypes":"Announced, Annual Inspection","checklistIds":[602176],"findings":[],"underAppeal":false}],"dcount":0,"icount":0,"ccount":0,"specialties":"Medication Assisted Substance Use Disorder Treatment","cmsCertNumber":null}