An employee at Provo Canyon School slammed a teen to the floor, leaving him with a concussion that went untreated for a week. There was a video, an upset mother who sought justice and an investigator who wrote that the school “clearly” mishandled the situation.

But the state agency that oversees youth treatment programs in Utah took no action back in 2016, and that was typical at the time. At another treatment center, a therapist sexually abused a patient. A teen even murdered an employee at one facility. But Utah’s Office of Licensing didn’t threaten to shut down the facilities or demand changes to prevent problems from recurring. It didn’t cite a single rule violation in any of those cases.

That hands-off approach was the norm until just two years ago, records show. In fact, until recently, the state almost never found fault with the way treatment programs handled incidents of abuse, neglect, harm, mistreatment, fraud or exploitation, according to an analysis by APM Reports.

Utah has long been a magnet for the nation’s most troubled teens. It has more residential treatment facilities than any other state, according to membership data from the National Association of Therapeutic Schools and Programs. In the past five years, parents, social workers and probation officers from every state in the country have sent nearly 12,000 children to Utah to treat problems, including addiction, mental illness and criminal behavior. But the lax regulations that likely encouraged the industry to flourish and bring hundreds of millions of dollars a year into the state also allowed abuse to go unnoticed and unpunished until recently.

The lack of enforcement came to light, thanks to a trove of never-before-seen records published this year by The Salt Lake Tribune, APM Reports and KUER. The three news organizations joined forces to publish five years of inspection reports and citations for rule violations from the 159 residential and wilderness programs that operated in Utah during that time period.

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The thousands of pages of documents reveal more about Utah’s historically lax approach to regulating the industry than what actually happens to the children. The reports cover only incidents when the state found rules had been broken. And until 2019, Utah hardly ever did.

Regulators found only four rule violations stemming from allegations of abuse or mistreatment in all of 2016, records show. They found fewer than 10 the following year and just over 20 in 2018.

During that time, the state was just starting to assign specialized investigators to look into whether facilities violated rules after serious allegations of abuse. Historically, the Utah Office of Licensing left such investigations to the same employees who review license applications and make sure facilities carry adequate insurance coverage. A previous APM Reports analysis of the annual inspections showed that those employees marked treatment programs as “compliant” 98% of the time.

“Prior to 2016, we actually didn’t even have an investigations team,” licensing director Amanda Slater explained.

The team started small, Slater said, with two investigators covering the state’s nearly 85,000 square miles. In 2018, the team quadrupled in size, allowing it to take incidents at youth treatment programs more seriously. And, for the first time, the state took steps to ensure that facilities were reporting incidents when they occurred.

“We always look at ourselves,” Slater said, “and see if we can improve.”

The larger team allowed the state to detect for the first time how widespread such violations actually were. Since 2019, the year Slater took over the office, her investigators have issued more than 100 citations a year, for violations stemming from such things as accidental injuries, excessive force and sexual abuse — more than five times as many as the year before she started. Some facilities have been cited more than 10 times since the state stepped up enforcement.

“Problems were certainly happening in 2016,” Utah state Sen. Mike McKell said after reviewing the APM Reports data analysis, “probably at the same levels of 2019.”

McKell led the charge to bring tougher regulation to the teen-treatment industry in Utah this year. He sponsored a new law that passed with overwhelming support. It provides for more frequent inspections and more investigators to enforce the rules.

“I think the problems have been ongoing for a long period of time,” he said.

‘A red flag’

In addition to the inspection and incident reports at the heart of the database, The Tribune also obtained a broader swath of public records on one of the state’s largest, oldest and most controversial facilities, Provo Canyon School. Those documents include all incident reports, not just those in which the state found violations, and they provide a window into the way Utah regulators used to handle abuse allegations.

The school was founded in the 1970s in the shadow of Brigham Young University, the premier educational institution of The Church of Jesus Christ of Latter-day Saints. Provo Canyon School has room for 286 residents at its two campuses. For nearly its entire history, the facility has faced accusations of abuse. Those allegations gained heightened attention in 2020 after celebrity Paris Hilton released a documentary about the abuse she says she and other former residents faced there in the 1990s.

Since 2017, state regulators have cited Provo Canyon School for violations 14 times, an analysis of the incident reports shows. But like most of the teen-treatment centers in Utah, it received no citations in 2016.

Michelle Westmoreland turned to the school for help when her son O’Dayvion was 14. She adopted him as an infant, and he was later diagnosed with reactive attachment disorder, schizophrenia, anxiety and an intellectual disability. He began living in residential treatment centers at age 11.

Nine months into his stay at Provo Canyon School, in April 2016, O’Dayvion was sweeping a hallway, one of the custodial chores assigned to residents. After halfheartedly working his way down the corridor with a broom, he got into an argument with another resident and then with an employee named Brandon Grebe.

Security camera footage shows that O’Dayvion shoved Grebe. The staffer then grabbed the teenager by the back of the neck, threw him to the ground and held him there. O’Dayvion continued to struggle, and another staffer stepped in to separate them. According to the Provo police report, the video appears to show Grebe striking O’Dayvion’s head.

“He caut my head and slaem it in the grown [sic],” O’Dayvion wrote in a document Provo Canyon School had him fill out at the time. O’Dayvion is Black, and he also wrote that Grebe called him the N-word, something Grebe denied. The security camera video that captured the tussle has no sound.

Westmoreland heard about the confrontation from O’Dayvion’s therapist, who told her a staffer had put O’Dayvion in a rough hold.

“It was a red flag,” Westmoreland said.

A few days after he was slammed to the floor, O’Dayvion told his father that his head and stomach hurt. Westmoreland said the school’s then-director, T.J. O’Reilly, told her it was an ear infection.

Westmoreland didn’t believe him. She insisted her son see a doctor, and eight days after the incident, Provo Canyon School agreed. It sent O’Dayvion to the emergency room, and a doctor diagnosed him with a concussion.

“That’s when I pretty much went into orbit,” Westmoreland said.

The police questioned Grebe, who told them he was only defending himself after O’Dayvion attacked him. The Provo City Attorney’s Office charged him with misdemeanor child abuse, though it later withdrew the case. Prosecutor Stephen Schreiner said he did not remember why he dropped the charges. Westmoreland recalled O’Dayvion didn’t want to testify. Grebe’s wife told APM Reports that he didn’t wish to comment.

A report from Utah Child Protective Services said Grebe was fired for violating Provo Canyon School’s use of force policy and using a racial slur.

CPS concluded that Grebe physically abused O’Dayvion by using excessive force during a physical restraint that its investigator deemed unnecessary. The investigator also believed that Provo Canyon School mishandled the situation.

“Clearly it is a violation of licensing,” she wrote.

At the time, the school was supposed to be under increased state oversight. In 2015, the Office of Licensing had placed it on notice after two cases in which staff used excessive force against kids and filed inaccurate reports about what happened. The state told the school it needed to come into compliance or face sanctions, including potentially losing its license.

But it was an empty threat. When Westmoreland contacted the Office of Licensing about the excessive force used against her son, it did little more than document her complaint.

“During this call I primarily listened,” a licensing employee wrote afterward. “She was very intent on telling her story and being heard.”

The Office of Licensing does not appear to have investigated whether Provo Canyon School did anything wrong, the department’s report shows. The state took no action against the school even though it was supposed to be under greater scrutiny, there was video evidence, and the facility waited more than a week to take the injured child to the hospital.

Universal Health Services Inc., the publicly traded company that owns Provo Canyon School, declined an interview request. In response to questions about O’Dayvion’s treatment, the company emailed a generic statement copied verbatim from its previous responses to media inquiries, which it posted on its website after Hilton’s documentary.

“Provo Canyon School was sold by its previous ownership in August 2000,” the statement began. “We therefore cannot comment on the operations or patient experience prior to that time.”

The violent encounter involving O’Dayvion occurred almost 16 years after UHS took ownership of the facility.

More regulation coming

Slater, the state’s licensing director, declined to speak about O’Dayvion’s case, because she wasn’t with the Office of Licensing at the time.

In an interview, she explained that her department’s job is to help treatment centers follow state regulations, not punish the staff.

“We can’t charge somebody criminally. We’re not Child Protective Services,” Slater said. “So, if we have an indication that something is wrong there, we would turn it over to those authorities that actually have that role and are designated to take care of that.”

Under Slater’s leadership, the Office of Licensing has become much more aggressive about citing facilities for rule violations after incidents like O’Dayvion’s, the data shows.

And, thanks to a new law that took effect in May, treatment programs now have more rules to follow, which will likely mean citations will increase further in the coming years, Slater said.

The new law will also double the number of investigators at the Office of Licensing from eight to 16. Facilities will have to undergo four inspections a year instead of one, and they will have to document every time a staff member uses a physical restraint on a resident or places them in seclusion.

“I think that it will make our office better,” Slater said. “I think it will make the industry better.”

The increased oversight comes too late for Michelle Westmoreland. She pulled O’Dayvion from Provo Canyon School six months after his concussion. He’s now in a group home in Nevada, closer to where she lives.

Westmoreland’s experience inspired her to try to help other families, and she now volunteers with the National Alliance on Mental Illness. When families ask her where to find help for their children, she tells them, “Don’t let it be Utah.”

APM Reports’ José Martínez and KUER News’ David Fuchs contributed to this article.

Editor’s note • This article is part of Sent Away, an investigative reporting partnership involving The Salt Lake Tribune, KUER and APM Reports.