R501-1-9. Investigations of Alleged Violations

  (1) Unlicensed Programs.

  (a) The Office shall investigate reports of unlicensed human service programs.

  (b) Investigation of an unlicensed human service program may include interviewing anyone at the site, neighbors, or gathering information from any source that will aid the Office in making a determination as to whether or not the site should be licensed.

  (c) An unlicensed human services program that meets licensure definition, but does not submit an application and fee, or fails to become licensed, shall be referred to the Office of the Attorney General, and the appropriate County Attorney.

  (d) The Office may penalize a licensed program at all program sites when a program adds or operates an unlicensed site that requires licensure by the Office.

  (2) Licensed Program Complaints and Critical Incidents.

  (a) The Office shall investigate critical incidents and complaints involving alleged licensing violations regarding a licensed human services program.

  (b) Complaints about licensees can come to the Office via any means from any source including the Office of Licensing email address: [e-mail].

  (c) The Office retains discretion to decline investigation of a complaint that is anonymous, unrelated to current conditions of the program, or not an alleged violation of a rule or statute.

  (d) Critical incidents that involve one or more clients and/or on-duty staff in a licensed setting or under the direct responsibility and supervision of the program shall be reported by the licensee as follows:

  (i) report shall be made to DHS and legal guardians of involved clients within one business day;

  (A) if the critical incident involves a client or service under a DHS contract, the critical incident report must be completed within 24 hours and may require a five day follow up report to the involved DHS Division;

  (B) if the critical incident involves a client or service to a youth currently in the custody of DHS or its Divisions an immediate live-person verbal notification to the involved Division is additionally required.

  (ii) Initial critical incident reports to DHS shall include the following in writing:

  (A) name of provider and all involved staff, witnesses and clients;

  (B) date, time, and location of the incident, and date and time of incident discovery, if different from time of incident;

  (C) descriptive summary of incident;

  (D) actions taken; and

  (E) actions planned to be taken by the program at the time of the report.

  (F) identification of DHS contracts status, if any.

  (iii) It is the responsibility of the licensee to collect and maintain and submit as requested original witness and participant witness statements and supporting documentation regarding all critical incidents that require individual perspectives to be understood.

  (3) Investigative Process.

  (a) In-person, or electronic investigations may include, but are not limited to:

  (i) a review of on or offsite records;

  (ii) interviews of licensee(s), person(s), client(s), or staff;

  (iii) the gathering of information from collateral parties; and

  (iv) site inspections.

  (c) The Office will prioritize investigations of reports of unlicensed programs, complaints regarding licensed programs, and critical incidents following an assessment of risk to client health and safety as follows:

  (i) priority allegations, as administratively identified by the Office as a potential imminent risk to the health and safety of clients, will require initial on-site contact by the Office within three business days. The Office may utilize law enforcement, Child or Adult Protective services, or other protection agencies to meet priority in on-site response;

  (ii) all other allegations will require that the Office initiate an investigation within ten business days.

  (d) Licensees and staff shall cooperate in any investigation.

  (e) The Office may report any allegations or evidence of abuse, neglect, exploitation, mistreatment, illegal activities or fraud to clients, clients' legal guardians, law enforcement, insurance agencies, the insurance department, the Division of Occupational and Professional Licensing, or any other entity determined necessary by the Office.

  (f) Pending investigations or those that do not result in a violation finding shall be classified as protected and only released in accordance with Utah Code Title 63G Chapter 2, Utah Government Access and Management Act.