summary: Visit conducted on __5-28-25______. Visit covered 10 main areas/topics. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: __Turnbridge - Townsend____________________________________

 TIME OF VISIT (FROM - TO):       __________________________         DATE:__5-28-25______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
SC - Program Director
BS - Program nurse
TH -  Case Manager

List of Areas / Topics covered during visit:
•	Census - 11 (full)
•	No staff openings. The program does not utilize per diem staff. Shifts usually exceed designated ratios so that if staff call out it does not have a major impact on staffing and programs can remain in ratio. Shifts run 8am-4pm, 4pm-12am and 12am-8am.
•	House is active with 11 females currently residing in the home.  However, there have been no significant events or AWOL's.  When questioned how they maintain order in the program, staff indicated that residents are allowed to go off campus for activities and that staff will take residents for individual activities that interest them.
•	Physical plant tour.  Bedrooms and common areas were clean and free from clutter.
•	Meals were being prepared in the kitchen. The program has staff (chef) who solely prepare meals for residents and staff.
•	The fire alarm on the side door (driveway) went off when opened.
•	The agency employs a staff who goes to all the Turnbridge programs and counts medication to make sure there are no discrepancies.  He arrived during the visit.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
   Terri Bohara                                                   5-29-25
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


state: CT

facility_name: CT Clinical Services dba Turnbridge (Townsend Ave.

summary: Visit conducted on _3-4-25_______. Visit covered 7 main areas/topics. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: _____Turnbridge - Townsend_________________________________

 TIME OF VISIT (FROM - TO):       ___Afternoon_______________________         DATE:_3-4-25_______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
SC - Program Director
SO - Covering Nurse
TH - Case Manager

List of Areas / Topics covered during visit:
•	Census - The census is currently 7.  Recent referrals for females have been slow.
•	There are currently no staff openings. All staff receive training in both CPR & PMT training within the first month of employment. The human resources department tracks the re-certification process for current employees. The program nurse is currently out on temporary leave. Coverage is being provided by another agency nurse.
•	The program does some gender specific programming, but the female residents often like to participate in the same activities that are offered to the male residents.
•	Physical plant tour. Common areas and bedrooms were clean and well organized. The kitchen had ample snacks available. Meals are prepared with the allergies and likes and dislikes of residents. An open bag of rice was found in a basement storage area. It was removed.
•	The program license will be converted from a Provisional to a Regular license.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
        Terri Bohara                                                   3-13-25
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on ___1-7-25_______________. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
TDCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: __Turnbridge - Townsend Ave. _________________________

 TIME OF VISIT (FROM - TO):       __________________________               DATE: ___1-7-25_______________

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
SC
CT

List of Areas / Topics covered during visit:
•	Census - 6
•	Currently there are no staff openings. Currently the majority of the staff are med admin certified.
•	There have been no major physical plant changes since the last visit.
•	The length of stay for residents can vary from a couple of months to several months, depending on need.  A discharge planner assists the family with identifying services in thire home area.
•	Physical plant tour. All of the bedrooms were fairly well organized and clean. Some minor marks in the wall were identified.
•	Discussion of the program treatment plans. The plans meet the current regulations. It was suggested that the roles staff play in helping residents meet their goals/objectives be clearly identified so as to give staff "credit" for the work that they do in assisting youth meet their goals.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of regulatory non-compliance identified during this visit:
•	No citations noted.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

___Terri Bohara___________________________            ____1-17-25_____________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

type: general

personnel: SC CT


summary: Visit conducted on __10-29-24______. Visit covered 8 main areas/topics. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ___Turnbridge - 980 Townsend___________________________________

 TIME OF VISIT (FROM - TO):       _____Morning_____________________   DATE:__10-29-24______

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
TM - Executive Director
Program Nurse

List of Areas / Topics covered during visit:
•	Census is currently 6.
•	There are no current staff openings. Holiday schedules are being prepared to accommodate staff time off.
•	Staff were preparing food for meals (Taco Tuesday).
•	Alarms have been added to some of the windows (those with access to a roof). All of the windows in the third floor bedroom have alarms. The program will look to install alarms on all of the bedroom windows. All of the bedrooms, common spaces and bathrooms were clean and organized. An agency cleaning crew comes in once a week.  "Deep cleans" are done by residents twice a week.
•	Educational and clinical services are offered off site.
•	Staff ratios include a manager and child care staff plus administrative staff on first and second shift and 2 staff on third shift.
•	A new parking area has been added behind the house as well as an additional outside security camera.
•	The controlled medication is kept upstairs in a locked box in the staff office, separate from the other medications which are maintained in the nurses office. The program only allows stimulants. The staff office has a camera.

Corrective Actions implemented as a result of previous visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Areas of regulatory non-compliance identified during this visit:

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.
     Terri Bohara                                              11-1-24
______________________________            _________________
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

personnel:
TM - Executive Director
Program Nurse


facility_name: CT Clnical Services dba Turnbridge/GH#168NORTH HAV

summary: Visit conducted on 1-8-26. Visit covered 15 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                        Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge: Adolescent Extended Care North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       10:00am-11:40am        DATE:  1-8-26

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Director of Adolescent Extended Care
•	Nursing Supervisor
•	Program Nurse
•	Assoc. Director of Adolescent Residential Care
•	Support Staff Manager
•	Kitchen Staff

List of Areas / Topics covered during visit:  This was an unannounced Licensing visit to obtain an update on the program and tour the physical plant. Meeting held with Managerial staff. Topics discussed included:
•	Census: 14 (7 males, 7 females).
•	Staffing: No vacancies; new program registered nurse began employment last month.
•	Medical:
    -	recent client illnesses;
    -	flu shots;
    -admission physical exam protocol;
    -	infection control protocol;
    -medication certified staff quarterly training topics & documentation.
    -Disinfecting high touch surfaces.
    -	Weight loss injectables administered by nursing staff for two clients.
•	May 2026 DCF relicensing inspection.
•	Incidents since last quarterly Licensing visit (2 hospital visits).
•	Recent holiday celebration activities.
•	Recreation: ski trips; indoor rock climbing, etc.
•	Meal times & seating.

Milieu Observation:
•	Clients attending offsite day program; one client with illness resting in bed (not observed).
•	Kitchen staff prepping food.

Physical Plant: Tour of the physical plant facilitated by staff.
•	All areas appeared very clean and organized.
•	Additional privacy covering has been added to windows in rear bedroom/ensuite bathroom.
•	Minor stains on couches and dining table to be addressed.
•	Carpeting on stairs to lower level to be cleaned or replaced.
•	Cleaning crew scheduled biweekly.
•	Driveways and walkways free of snow and ice.
•	Food storage; snack availability.
•	Some touch-up painting since last Licensing visit.
•	Ensure paper towels are placed in dispensers at all sinks.

Corrective Actions implemented as a result of previous visit: Regulation compliance plan is pending following a semiannual review of personnel files last month.

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW			                         Date: 1-9-26
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	Director of Adolescent Extended Care
      File|


summary: Visit conducted on 12-15-25. Visit covered 1 main areas/topics. Found 9 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                               Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge: Adolescent Extended Care North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       12:30pm-4:30pm        DATE:  12-15-25

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	President

List of Areas / Topics covered during visit: This was a scheduled semiannual personnel file review. Thirteen (13) personnel files of recently hired staff were reviewed. Files are well organized. See 'Areas of Regulatory Non-compliance' below.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:

17a-131. 	Cardiopulmonary resuscitation training required for persons who directly supervise children.
•	Evidence of current CPR certification was not found in five files (AH-D, AA, AJ, MJM, TS).

17a-145-64.	Personnel policies and procedures.
•	Evidence of TB testing results reflects that the results were obtained more than three months prior to hire rather than immediately prior to assuming duties.

•	Physical exam documentation does not contain the date of the exam in one file (DD).

17a-151.	 Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	Evidence of a background check of the child abuse and neglect registry in any state in which such person or individual resided in the preceding five years was not conducted using one employee's full name (AH-D).

•	Evidence of a background check of the child abuse and neglect registry in any state in which such person or individual resided in the preceding five years was not conducted for one employee (DD, state of Virginia).

46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
•	Evidence of restraint training provided by the facility was not found in seven files (AH-D, AA, AJ, DD, JG, MJM, TS).

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW			                                    Date: 12-22-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	File|

description: D, AA, AJ, DD, JG, MJM, TS).


summary: Visit conducted on 11-20-25. Visit covered 11 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                      Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge: Adolescent Extended Care North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       10:00am-12:15pm        DATE:  11-20-25

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Director of Operations
•	Program Director
•	Program Nurse
•	Assoc. Director of Adolescent Residential Care
•	Support Staff Manager
•	Kitchen Staff

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the physical plant and obtain an update on the program. Meeting held with Managerial staff. Topics discussed included:
•	Census: 13 (7 males, 6 females); one admission and one discharge scheduled for tomorrow.
•	Staffing: No vacancies; coverage plan for nurse's impending maternity leave; newly hired nurse to start next month.
•	Average length of stay for clients; interagency transfers from residential treatment programs.
•	Wellness Plan review cycle.
•	2026 relicensing inspection.
•	Incidents since last quarterly Licensing visit; staff retraining.
•	Holiday celebration activities: Halloween, Thanksgiving, Christmas and Christmas tree.
•	Resident Liaisons: one male, one female; duties; community trips; support to Case Manager.
•	Vehicle monitoring; two program vehicles.
•	Client allergy communication, protocol.
•	Alternative meal entrée available at client request.

Milieu Observation:
•	All clients attending offsite day program.
•	Introduction to Director of Operations.
•	Two Kitchen staff prepping lunch.
•	Landscaping company conducting leaf removal.

Physical Plant: Tour of the physical plant facilitated by staff.
•	All areas appeared very clean and organized.
•	Discussed ensuring client privacy from neighboring houses.
•	Battery operated 'pop lights' on ceiling of client bedroom to be removed.
•	Med room access.
•	Snack station, client refrigerator in Kitchen; nursing approves all snacks.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                                                    			Date: 11-20-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	Program Director
File|


summary: Visit conducted on 8-21-25. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                        Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge: Extended Care North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       10:00am-12:15pm        DATE:  8-21-25

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Program Nurse
•	Assoc. Director of Adolescent Extended Care
•	Support Staff Manager
•	Kitchen Staff
•	Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the physical plant and obtain an update on the program.

Meeting held with Managerial staff. Topics discussed included:
•	Census: 11 (6 males, 5 males): admission scheduled for tomorrow.
•	ICPC forms required for interagency transfers.
•	Staff vacancies: No vacancies. Program Nurse has scheduled maternity leave in the next quarter, new Turnbridge nurse hired to fill in; overnight on-call Clinical services available.
•	Client supervision: Staff positioned at bedroom hallway entrances on overnight shift; minimally one female staff on duty at all times.
•	Incidents: No significant incidents in past three months.
•	Recreation events scheduled three times per week; off-site wellness activities also scheduled three times per week; summer events at Killingworth property.
•	Transportation.
•	Laundry procedures.
•	Maintenance staff scheduled at house every day.
•	Client personal money.
•	Limiting internet access on televisions; new TV's ordered for bedrooms with Roku compatibility.
•	Mail package delivery procedures.
•	Food Services: Menu postings, new additional lunch options; discussed possible cooking activities for life skill development; staff meals.

Milieu Observation: One client observed in program with several staff present; interview with client who reported high satisfaction with his time in the program, staff interactions and clinical services.

Physical Plant: Tour of the physical plant facilitated by staff.
•	All areas appeared very clean and organized.
•	Section of exterior siding appears warped due to grill.
•	Several picnic tables in the yard are in need of refinishing.
•	Stains observed on living room couch.
•	Discussed mattress replacement process.
•	Dresser drawer missing in room #6, reportedly removed by Maintenance for repair.
•	Stain observed on rug in room #7.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW			                                      Date: 8-22-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	Program Director
      File|


summary: Visit conducted on 7-8-25. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                         Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge: Extended Care North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       8:30am-11am        DATE:  7-8-25

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	CEO

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review for employees hired since December 2024.

Seven (7) personnel files were reviewed. Files are extremely well organized. No regulatory deficiencies were noted.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW			                               Date: 7-8-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	Program Director
      File|


summary: Visit conducted on 5-1-25. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                    Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge: Extended Care North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       10:00am-12:30pm        DATE:  5-1-25

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Program Nurse
•	Nursing Supervisor
•	Assoc. Director of Adolescent Extended Care
•	Support Staff Manager
•	Kitchen Manager

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the physical plant and obtain an update on the program.

Meeting held with Managerial and Nursing staff. Topics discussed included:
•	Census: 7 (3 males, 4 females); admission expected on this date. Three males discharged this week.
•	Staff vacancies: 0.
•	Incidents:
o	Peer assault occurred last weekend, Careline and Police notified, two males discharged as a result. Staff facilitated victim pressing charges. One male aggressor relocated to another Turnbridge program, went AWOL and subsequently sent to Yale Hospital for evaluation.
o	Inappropriate alleged peer interaction in March.
•	Bullying: Staff to draft policy with procedures; training residents and staff on policy. Issue to be reviewed with residents 5-4-25. Policy and trainings to be implemented within 45 days.
•	Client supervision: Staff stations for client supervision during awake and overnight shifts; possible modification to bedroom hallway doors to improve client supervision (window), staff should be positioned in bedroom hallways when clients are in bedrooms.
•	House security; routine video footage review for quality assurance purposes; door at bottom of lower-level staircase remains locked when area is unoccupied.
•	Obtaining a digital camera for use by nursing staff.
•	Medication administration staff roster.
•	Assigned Maintenance worker scheduled at the house several times per week for routine maintenance, touch-up painting, etc.
•	Bathroom door locks.
•	Off-site recreation events.
•	One female resident has off-site job at food establishment.
•	Process for clients' personal money (access, accounting oversight at corporate level, etc.)

Milieu Observation:
•	All clients off site attending day program.
•	Landscapers on site.

Physical Plant: Tour of the physical plant facilitated by staff.
•	All areas appeared very clean and well organized.
•	Privacy film missing on two windows in large bedroom with ensuite bathroom, window blinds present.
•	Soda machine: phasing out sugary sodas, adding juices.
•	Client lockers for securing valuables, personal snacks, etc.

Incident Response Note: IRN completed 4-9-25 for a late March 2025 alleged inappropriate peer interaction.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW			              Date: 5-1-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	Program Director
      File|


summary: Visit conducted on 2-5-25. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                        Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge Extended Care -North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       1:30pm-3:15pm        DATE:  2-5-25

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Nurse
•	Nursing Supervisor
•	Assoc. Director of Operations
•	Assoc. Director of Adolescent Extended Care
•	Resident
•	Support Staff Manager
•	Food Services Coordinator

List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to tour the physical plant and obtain an update on the program.

Meeting held with Program Director, Nurse, Nursing Director, and an Associate Director. Topics discussed included:
•	Census: 11 (7 males, 4 females); pending admission; new male admission from Killingworth RTC.
•	Staff vacancies: 0.
•	DCF Med certified staff: 20 staff are med certified, including managers; med administration during off site activities.
•	Incidents during the past three months (EMS calls, AWOL's, hospital visits, agency vehicle theft).
•	Access codes on doors changed frequently for security; program vehicle key storage in lock box.
•	Client supervision procedures when off site; Community-based recovery meetings for clients twice per week.
•	Recreation: Recent holiday celebrations; three recreation and three wellness activity trips scheduled each week; upcoming ski trip, snow tubing, movie theaters, go-karts, trampoline park, hockey game, weekly indoor boulder climbing, etc.

Milieu Observation:
•	Upon arrival to the house, two Kitchen staff observed preparing food.
•	Newly admitted client observed in living room watching television; brief interview conducted.
•	Associate Director of Operations and the Support Staff Manager greeted this Regulatory Consultant. Residents reported to be off-site at day program.
•	Posted weekly menu observed. Food Services Coordinator reported on lunch cards completed by residents each day indicating preferred meal choice.

Physical Plant: Tour of the physical plant facilitated by staff.
•	All areas appeared clean.
•	Unmade beds observed in three bedrooms; housekeeping expectations are included on client Wellness Plans.
•	Paper towels missing in three bathrooms - corrected during Licensing visit.
•	Mildew observed on shower curtain in bathroom on boys' wing.
•	Dents observed on Kitchen refrigerator doors.
•	Client hygiene baskets with supplies observed stored in showers; used wash cloths observed drying on shower door. Burnt bulb observed in bathroom on female wing.
•	New attractive metal beds observed in bedrooms on female wing.
•	Some clients' personal pillows observed without cases; program does provide pillows to new residents.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                       			Date: 2-6-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	Program Director
      File|


summary: Visit conducted on 12-10-24. Visit covered 1 main areas/topics. Found 2 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                  Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge Extended Care -North Haven

TIME OF VISIT (FROM - TO):       morning                              			DATE:  12-10-24

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
             •	CEO

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review. Thirteen personnel files were reviewed. Files are well organized. It was noted that a kitchen staff (MA) does not contain documentation of a completed physical exam prior to hire. See 'Areas of Regulatory Non-compliance' below.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:
17a-131. Cardiopulmonary resuscitation training required for persons who directly supervise children.
•	One personnel file of a direct care worker (MS) does not contain evidence of CPR certification.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW                                       			Date: 12-11-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.

Cc: 	File|

visit_time: morning


summary: Visit conducted on 11-13-24. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                        Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge Extended Care -North Haven - Co-Ed

TIME OF VISIT (FROM - TO):       10:00am-2:10pm        DATE:  11-13-24

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Nurse
•	Nursing Supervisor
•	Assoc. Director
•	Case Manager
•	Resident
•	Operations Director

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with Program Director, Nurse, Nursing Director, Case Manager and Associate Director. Topics discussed included:
•	Census: 9 (7 males, 2 females; nonbinary male client assigned to single bedroom in female wing, pending referrals.
•	Staff vacancies: 0.
•	Amended childcare facility license issued to program in September 2024 to serve a co-ed population for a co-ed population.
•	Staffing transfers when program reverted to serving co-ed population.
•	Incidents during the quarter: one call for EMS, client sent to hospital for dysregulation, subsequently discharged.
•	Incident Response Note completed by Licensing last month as follow up to incident in the program; co-ed rec activities with other Turnbridge programs on hold until further notice.
•	Client supervision: Third shift staffing levels, staff supervision stations, headcount practice, bed check practice, supervision protocol for when clients are in lower level of house.
•	Suggestion of quality improvement process to identify areas for improvement.

Meeting held with one male client at request of the program. Issues discussed brought to the attention of Program Director for follow up.

Physical Plant:
•	Tour of the physical plant. All areas appeared very clean and organized.
•	Some walls in bedrooms in need of touch-up painting.
•	Condition of fabric headboards in bedrooms.
•	Suggestion to install door on laundry room alcove as well as second video camera in this area.
•	Add hooks or racks for drying bath towels.

Milieu observation:
•	One client in the house who refused to attend day program, all other clients off site at day program.
•	Numerous staff arrived for scheduled house meeting.
•	Kitchen staff preparing lunch.
•	Contractor arrived during visit to repair a washing machine.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The regulation compliance plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                                    			Date: 11-13-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: 	Program Director
Assoc. Director
File|


summary: Visit conducted on 8-22-24. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                         Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge Extended Care -North Haven - Girls

TIME OF VISIT (FROM - TO):       10:00am-12:30pm        DATE:  8-22-24

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Associate Director
•	Nurse
•	Program Director
•	Food Services Director
•	Day Manager

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with Program Director, Nurse, and Associate Director. Topics discussed included:
•	Census: 12 females, with two vacancies.
•	Staff vacancies: 0; new Program Nurse; Case Manager promoted to Associate Director.
•	Incidents during the quarter: Two incidents of AWOL, two incidents of calls for EMS for one client, Fire Dept. response to carbon monoxide alarm.
•	DCF Nursing standards and Medication Administration program standards.
•	Summer recreation activities.
•	Staffing levels on each shift; client supervision practices.
•	Plans for pet therapy to begin Fall 2024.
•	Client mail and telephone practices.
•	Search practices; children's rights statute.
•	Program will revert back to co-ed population when a new Turnbridge program opens in New Haven in Fall 2024.
•	Bedroom assignments for transgender clients if needed.

Physical Plant: Tour of the first floor of the physical plant facilitated by Program Manager and Nurse.
•	All areas observed to be very clean and organized.
•	Minor wall damage in some bedrooms; interior repainting of bedrooms scheduled for Fall 2024.
•	Discussion on floor covering, air purifiers, mattress checks, storage of cleaning chemicals, ensuring security of garage building.

Milieu observation: Clients off-site at day program. Lunch prep in process by Food Services Director. Numerous staff on duty in the building. Interviews with Day Manager and Food Services Director.

Case records: Follow-up review of treatment plans (Wellness Plans) and discharge summaries on select files.

Corrective Actions implemented as a result of previous visit: Regulation Compliance Plan (RCP) submitted by the program following the June 2024 biennial relicensing inspection. The RCP was accepted by the Department and license renewed.

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                          			Date: 8-23-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: Program Director|


raw_content:
June 24, 2024

Mr. Brett Tiberio
President
CT Clinical Services, Inc.
189 Orange Street
New Haven, CT  06510

Re: Turnbridge NORTH HAVEN female adolescent extended care/sober living
License #: CCF/GH # 168
Regulatory Consultants: Kathleen Forsythe & James Funaro

Dear Mr. Tiberio,

On June 18 & 20, 2024, a biennial re-licensing inspection was conducted for the Turnbridge North Haven girls extended care/sober living residential program, located at 600 Middletown Ave., North Haven, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124.

Additionally, an onsite review was conducted by DCF Nurse Consultant Errolee Miller, RN on 6-3-24 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A 'full standard of compliance' is documented in the report, which will be forwarded to the program. A copy of the nursing review site visit summary report is also included with this report.

Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a licensing regulation compliance plan (RCP) to address each area of noncompliance. The completed regulation compliance plan and any applicable supporting documentation must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report.

The areas of regulatory noncompliance are as follows:

17a-145-52  	 Interstate Placement of Children.
'Interstate Compact on the Placement of Children - Report on Child's Placement Status' (form 100B) was not found in five case records (EC, KS, OK, SR, VT) to reflect a change in placement from a previous Turnbridge program in another town. No new ICPC 100B forms were completed to document the change in placement to the extended care/sober living program in North Haven, CT.

In four (4) open records reviewed (EC, KS, OK, SR), letters from the Turnbridge Admissions Department to Interstate Compact incorrectly state that the child was admitted to the Woodbury, CT Residential Treatment program rather than the Killingworth, CT Residential Treatment program. The Woodbury, CT campus has served only males since August 2022.

17a-145-06   	Discharge of a Child.
The discharge summary report in one closed case record (SG) does not include information on if the client left the program with the legal guardian. Discharge of a child shall only be to the legal guardian, or to someone else with written authorization from the legal guardian.

17a-145-98   	Case Records. Reports. Confidentiality.
The individual treatment plans (Wellness Plans) in thirteen (13) open case records do not contain a client's signature in accordance with agency policy. Additionally, the plans do not contain discharge planning information, to include a target date for discharge.

******************************************************************************

Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision, the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe, LCSW
Regulatory Consultant

Cc: Program Director|

report_type: unstructured


summary: Visit conducted on 5-2-24. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                          Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge Extended Care -North Haven - Girls

TIME OF VISIT (FROM - TO):       1:45pm-3:40pm        DATE:  5-2-24

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Nurse
•	Program Director
•	Food Services Director
•	Daytime Manager
•	Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with Program Director, Nurse, and Daytime Manager. Topics discussed included:
•	Census: Program is full with 14 female residents; one under-age waiver in place.
•	Staff vacancies: 0
•	Incidents during the quarter: One call for EMS during an off-grounds recreation trip.
•	Elements of the biennial relicensing inspection scheduled for June 2024.
•	Overnight headcount procedures; video camera locations in common areas, documented bed checks every 15 minutes, random video footage monitoring by program management.
•	Clients attend clinical day programming off site Monday through Friday.
•	Rec & leisure activities during past quarter.
•	Planned activities for summer.
•	Education services: Advantages accredited on-line school, tutor, graduation ceremony scheduled for June.
•	Plan to convert program back to co-ed population in summer 2024 when new female program opens in New Haven.
•	Menu cycles, nurse approval of menus.
•	Ensuring address of program is included on reports submitted to DCF.
•	Topics for quarterly Med Admin staff training.

Physical Plant: Tour of physical plant facilitated by Program Manager.
•	All areas observed to be very clean and organized.
•	Discussed sink water temperature, locks on kitchen refrigerators, damage to soda machine cover, minor stains on new living room couch. Minor damage to bedroom wall from décor removal.
•	Enhancing privacy on some bedroom windows.
•	Client snack refrigerator; snacks available at all times.

Milieu observation: Majority of clients off site at day program.
•	One resident in program during visit preparing for off-site job interview.
•	Brief interview conducted; reported the program is helpful and would recommend to others.
•	Two direct care staff and two food service workers in the building.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. - No Licensing Regulation Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                            			Date: 5-3-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 2-29-24. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                       Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge Extended Care -North Haven - Girls

TIME OF VISIT (FROM - TO):       10:30am -12:15pm         DATE:  2-29-24

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Nurse
•	Case Manager
•	Senior Case Manager
•	Lead Support Staff
•	Food Services Director
•	Program Director

List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with program Nurse and Case Manager. Topics discussed included:
•	Census: Program is full with 14 female residents.
•	Staff vacancies: 0
•	No major incidents in the past quarter.
•	Relicensing inspection scheduled for June 2024.
•	Headcount procedures on awake and overnight shifts; headcount documentation.
•	Snow removal procedures.
•	Bedding disinfection procedures after a discharge.
•	Length of stay.

Tour of physical plant facilitated by Program Manager. All areas observed to be very clean and organized.
Discussion included:
•	Locks and alarms on emergency exit doors tested.
•	Activity schedules: recreation and 'recovery in movement' activities (salt cave, Pilates, etc.).
•	Adding area rug in large bedroom.
•	Buttons missing on some pillowed bed headboards; furniture replacement schedule.
•	Deep clean schedule by clients, store trips for rewards.
•	Freezer in pantry in need of cleaning.
•	House cell phone for client use.
•	Client search procedures, documentation, and client rights on searches.
•	Client phone log.
•	New couch in living room; couch in lower level in need of surface cleaning.
•	Mattress replacement schedule.
•	Bedroom hallways:
o	Two doors at bedroom hallways scheduled for replacement;
o	Suggestion of keeping bedroom hallway doors open on overnight shift for enhanced client supervision;
o	Staff stations on overnight shift;
o	Video monitoring; quality assurance review of footage by management;
o	Suggestion of perimeter alarms;
o	Increasing frequency of overnight bed-checks from 30 minutes.

Milieu observation: All residents at day program during visit; two male direct care staff observed in house with clinical, nursing and food services staff.

Corrective Actions implemented as a result of previous visit: A service development plan was previously submitted by the program following a personnel file review in December 2023. The SDP was accepted by the Department.

Areas of regulatory non-compliance identified during this visit: None.

Please submit a Licensing Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. -No Licensing Compliance Plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                        			Date: 3-4-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 12-7-23. Found 4 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                               Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program North Haven

TIME OF VISIT (FROM - TO):       12:30pm-2:30pm              DATE:  12-7-23

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	HR Dept.
•	Executive Director

List of Areas / Topics covered during visit:  This was a scheduled remote semiannual personnel file review for those staff hired since July 2023.

Personnel file review:
•	Eight personnel files were reviewed. See Areas of Regulatory Noncompliance below.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:
17a-145-22 Personnel Policies and Procedures.
•	One file (PM) contained evidence of a physical exam completed approximately 3.5 months prior to hire date rather than immediately prior to hire.
•	Four files (HR, LL, NJ, GM)) contained documentation of physical exams obtained after hire rather than immediately prior to hire.
•	Five files (PM, HR, LL, NJ, GM) contained documentation of TB testing results that were obtained after hire rather than immediately prior to hire.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW                                    			Date: 12-7-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: File|

description: 22 Personnel Policies and Procedures.

personnel:
•	HR Dept.
•	Executive Director


summary: Visit conducted on 10-12-23. No compliance issues identified. Implemented 1 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                       Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program North Haven

TIME OF VISIT (FROM - TO):       10:30pm-12:45pm              DATE:  10-12-23

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Nurse
•	Case Manager
•	Food Services Worker
•	Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with The Program Director and the day Nurse on duty. Topics discussed included:
•	Census: Program currently has five female residents.
•	Program submitted an application to convert from a co-ed program to an all-female program.
•	Incidents/significant events that occurred in the past three months.
•	Staffing: No staff vacancies. Additional case manager recently hired. Direct care staff are female; two male food service workers. Part-time male Program Director splits time with an adolescent male program.
•	Recreation: Co-ed events will be scheduled with new all-male program.
•	Transportation: Program has one agency vehicle assigned. Turnbridge provides transportation to day program in a bus Monday-Friday.
•	Food services: Program provides meals for residents at day program.
•	Video surveillance monitoring and quality assurance process.
•	DCF relicensing inspection to be held in late June 2024.
•	Search practices
•	Ratios: 1:4. Four direct care staff scheduled for 1st shift, 4 staff on 2nd shift, 3 staff on 3rd shift.
•	Emergency preparedness plan for inclement winter weather; generator on site.
•	Fire drill evacuation reports for the past quarter.

Tour of physical plant. All areas observed to be very clean and organized.
•	New replacement couches for education room and living room ordered; expected delivery scheduled for November.

Milieu Observation:
Four female clients off site attending day program. Food service worker preparing dinner. Case Manager, day nurse and two direct care staff observed in the program. One female resident preparing to depart to airport for family visit in NC.

Interview with female resident. Topics discussed:
•	Safety
•	Staff & peer relationships
•	Helpfulness of program: Client states Turnbridge is the best of four treatment programs she has attended.
•	Food quality

Corrective Actions implemented as a result of previous visit: A service development plan was submitted to DCF by the Turnbridge North Haven program following a July 2023 Licensing visit that addressed regulatory citations related to personnel files. The plan was accepted by the Department.

Areas of regulatory non-compliance identified during this visit: None.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. - A service development plan is not required following this Licensing visit.

Kathleen Forsythe, LCSW                                                    			Date: 10-16-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 7-12-23. Found 7 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                      Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program North Haven

TIME OF VISIT (FROM - TO):       1:30pm-3:00pm              DATE:  7-12-23

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Nurse
•	Food Services Worker
•	Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with The Program Director and the day Nurse on duty. Topics discussed included:
•	Census: Program is at capacity with seven male and seven female residents
•	Incidents/significant events that occurred in the past three months
•	Staff vacancies: 0
•	Safety checks during awake and overnight hours; staff stations and duties on overnight shift
•	Interstate compact forms for out-of-state clients
•	Recreation
•	Proposed new residential program in New Haven
•	Proposed garage renovation
•	Client search procedures
•	Client supervision procedures

Tour of physical plant. All areas observed to be very clean and organized.
•	New alarms installed on emergency exit doors

Interview with male resident. Topics discussed:
•	Safety
•	Staff & peer relationships
•	Helpfulness of program
•	Food quality

Milieu observation: dinner prep, one client having snack in kitchen; evening nurse on duty in the Medication room

Personnel file review:
•	Five (5) personnel files were reviewed remotely. See Areas of Regulatory Noncompliance below.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit:
17a-145-22 Personnel Policies and Procedures.
•	One file (N.) contained evidence of a physical exam and TB testing results completed after hire.
•	One file (N.) did not contain the results of an out-of-state child protective services background check from NY.
•	One file (M.) did not contain the results of an out-of-state child protective services background check from NY.
•	One file (A). contained evidence of a criminal history background check through the CT State Police completed after hire.

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW                     			Date: 7-14-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|

description: 22 Personnel Policies and Procedures.


summary: Visit conducted on 4-26-23. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

F                                                    Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program North Haven

TIME OF VISIT (FROM - TO):       10:00am -1:50pm         DATE:  4-26-23

AGENCY PERSONNEL WHO PARTICIPATED:
        Job Titles:
•	Program Director
•	Nurse
•	Support Staff
•	Food Services Director
•	Client

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and tour the physical plant.

Meeting held with The Program Director and the Nurse on duty. Topics discussed included:
•	census - program is full with seven male and seven female residents
length of stay
•	weekly Clinical rounds
•	incidents/significant events that occurred in the past three months, EMS calls, hospital visits, etc.
•	program schedule
•	staff vacancies = 0
•	30 minute safety checks; staff stations on overnight shift
•	ensure case records include incident reports
•	medication administration certified staff
•	medication errors for the quarter; Medication now distributed out of Nursing office; Dutch-style door installed

Tour of physical plant. All areas observed to be clean and organized. Discussion included:
•	privacy film has been added to lower half of bedroom windows
•	locks and alarms on emergency exit doors tested
•	soda machine in Kitchen
•	storage area for resident personal items
•	water temperature

Interview with female resident. Topics discussed:
•	Resident safety
•	Recreation/leisure activities on and off site
•	Menus, snacks
•	Peer relationships
•	Staff helpfulness
•	Off-site clinical programming
•	Staff supervision
•	Bedtime routine
•	chores

Milieu observation: Lunch and dinner prep, two clients returning from day programming and eating lunch.

Case record review: Two case records were reviewed remotely after the site visit.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: N/A

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above. -No service development plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                                       			Date: 4-28-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Program Director|


summary: Visit conducted on 1-12-23. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                            Field Visit Reporting Form
This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge -
Adolescent Extended Care Program, North Haven, CT

TIME OF VISIT (FROM - TO):           12:15pm-2:45pm               DATE: 1-12-23

AGENCY PERSONNEL WHO PARTICIPATED:
                                Job Titles:
Program Director
Kitchen Manager
Kitchen Assistant
Maintenance Worker
Direct Care Worker

List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to tour the physical plant and obtain a program update.

A meeting was held with the Program Director. Topics discussed:
•	Census = 14
•	Average length of stay
•	Incidents
•	Recent COVID cases with staff and one client
•	Headcount process, frequency, recording
•	Laundry schedule
•	Security camera monitoring; staff stations
•	Call from Executive Vice President with Regulatory Consultant
•	Age/over census waiver form

Milieu Observation

A tour of the physical plant was facilitated by the Program Director:
•	All common areas appeared very clean and organized; Male bedrooms appeared unkempt.
•	House interior temperature
•	Food storage in kitchen and food storage room
•	New Dutch-style door installed in Nursing office
•	Emergency exit security
•	Hygiene products stored in showers
•	Storage room with unsecured door in basement
•	Storage of mops/brooms

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during the visit.

Kathleen Forsythe, LCSW                                   			Date:    1-13-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: Executive Vice President
      File|

facility_name: CT Clinical Services d/b/a Turnbridge -


summary: Visit conducted on 12-12-22. Found 1 compliance issues.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

                                                      Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Extended Care Program, North Haven, CT

TIME OF VISIT (FROM - TO):              morning               DATE: 12-12-22

AGENCY PERSONNEL WHO PARTICIPATED:
                              Job Titles:
Executive Vice President

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review of staff hired since July 2022. The review was conducted remotely. One personnel file was reviewed.

Corrective Actions implemented as a result of previous visit: N/A

Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during the review.

Kathleen Forsythe, LCSW                                          			Date: 12-14-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: Executive Vice President
      File|


summary: Visit conducted on 10-25-22. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: _CT Clinical Services d/b/a Turnbridge - North Haven program

TIME OF VISIT (FROM - TO):    10:30am- 1:30pm                 DATE: 10-25-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Program Director
APRN
Chef
Culinary Assistant

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the physical plant, as well as obtain an update on the program since the relicensing inspection conducted in July 2022.
Discussion included:
•	Census = 14 (7 males, 7 females). The program is full.
•	Staffing: Staff to client ratios, staffing schedule, staffing vacancies (none), staff supervision procedures including bed checks, staff stations on the overnight shift, camera monitoring.
•	Program: Resident daily schedule/routine, fall recreation activities, academics, clinical services provided at Turnbridge OPCC, police involvement for two incidents of AWOL, medical incidents, 136 report, search procedures, telephone procedures, drug testing procedures.
•	Food Services: Menu cycles, menu posting and approval process, food storage in refrigerators and supply storeroom, snack availability, refrigerator/freezer temperatures, ensuring food safety when transporting meals to OPCC. Lunch on this date was plentiful and attractively presented.
•	Nursing: Nursing coverage, APRN and RN responsibilities, drug testing procedures, water availability in nursing office.
•	Physical plant tour: All areas of the home appeared clean, organized, attractive and decorated for the season. Discussed enhancing client privacy on exterior windows, enhancing infection control procedures in shared bathrooms, and wall decor. Residents were observed returning from clinical day program. One client was observed to be resting in bed due to mild illness. A registered nurse was on duty in the home.

Corrective Actions implemented as a result of previous visit: A service development plan to address regulatory deficiencies noting during the relicensing inspection was accepted by the Department and a renewed license was issued in August 2022.

Areas of regulatory non-compliance identified during this visit: No regulatory deficiencies were noted during this visit.

Kathleen Forsythe, LCSW                              		Date: 10-28-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: Executive Vice President
      Program Director|


raw_content:
July 28, 2022

Dr. Christopher Cutter, PhD.
Executive Director -Turnbridge Adolescent Programs
CT Clinical Services, Inc.
189 Orange Street
New Haven, CT  06510

Re: Turnbridge NORTH HAVEN extended care
License #: CCF/GH # 168
Regulatory Consultants: Kathleen Forsythe & Terri Bohara

Dear Dr. Cutter,

On July 26-27, 2022, a biennial re-licensing inspection was conducted for the Turnbridge North Haven co-ed extended care residential program, located at 600 Middletown Ave., North Haven, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124.

Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-30-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report.

Listed below are the areas of DCF regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and complete a service development plan (SDP) to address each area of noncompliance. The completed service development plan and applicable supporting documentation must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report.

The areas of regulatory noncompliance are as follows:

17a-145-64	Personnel Policies and Procedures.
A review of documentation in seven (7) personnel files identified the following deficiencies:
•	Seven (7) files did not contain evidence that the employee received a physical examination immediately prior to assuming duties (KP, NR, AK, CT, CB, DC, MR).
•	Three files did not contain evidence that TB testing results were obtained immediately prior to assuming duties (AK, DC, MR).
•	Evidence of current CPR training was missing in two files (CB, DC).
•	CT State Police criminal history background check results were obtained after the hire date in three files (AK, CB, NR).
•	DCF protective services background check results were obtained after the hire date in four files (KP, NR, CB, DC).

17a-145-75	Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, medicines, and Instruments. Sick Room, Telephone.
b) Evidence of a physician's quarterly review of required policies (administration of first aid; care of residents with minor illness, injuries or special conditions; administration or use by residents of patent medicines) was not found as follows:
2020:	4th quarter
2021:	2nd, 3rd,  & 4th quarters
2022:	2nd quarter

17a-145-86	Instructions in Safety Procedures. Supervision.
Based on a review of fire drill evacuation records for the North Haven Residential program for the licensed period, it was found that the facility did not have documentation of fire drills as follows:
2020:	1st shift: 4th quarter
2nd shift: 3rd quarter
3rd shift: 3rd 7 4th quarters

2021:	1st shift: 1st, 2nd, 3rd, 4th quarters
3rd shift:  1st, 2nd, 3rd, 4th quarters

2022;	1st shift: 2nd quarter
3rd shift: 1st & 2nd quarters

814e - Physical Restraint, Medication & Seclusion of Persons Receiving Care, Education or Supervision in an Institution or Facility:    46a-154	Internal Monitoring, Training and Development of Policies and Procedures Required and Subject to State Agency Inspection.
•	Written policy on seclusion was not provided for review.
•	Written policy addressing restraint does not include all elements listed in the statute.

*********************************************************************************************

Once the Licensing Unit has reviewed and accepted the service development plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four
month license for the program will be made.  Until DCF makes this decision, the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe
_________________________
Kathleen Forsythe, LCSW
Regulatory Consultant

Cc: Adolescent Program Director, Executive Vice President, Executive Director of Residential Services|


facility_name: Discovery Practice Management, Inc. / Fairfield

summary: Visit covered 13 main areas/topics. Found 1 compliance issues.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Discovery Practice Management/ Mood and Anxiety Fairfield Group Home

 TIME OF VISIT (FROM-TO) 11:05am to 12:30pm:             DATE: November 21, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Associate Vice President of Operations
Program Director

Areas / Topics covered during visit:

•	Census: The program had 2 males, and 2 females placed at the facility at the time of the quarterly visit.
•	Admissions: In the last quarter, the program confirmed that there were thirteen new admissions.
•	Discharges: The program reported that in the last quarter, there were 3 unplanned discharges and 7 planned discharges.
•	Staffing: The facility staffing consists of 8 full-timers,5 part-timers and 8 per-diem employees.
•	Staff vacancies: The program reported that in the last quarter, it had 1 part-time weekend shift vacancy and 1 full-time therapist vacancy.
•	Staff hires: The program confirmed that there were 4 new MHT hires in the last quarter.
•	Physical plant: A walkthrough of the building was conducted with program staff to evaluate the group home's compliance with regulatory standards.

•	SIU Reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
17a-145-73: Sleeping accommodations. Upon inspection of the physical plant, bedroom one contained a dresser that had a missing knob. Bedroom two contained only one dresser for two residents, and an additional dresser is required. The room also contained a broken window mini blind, which needs to be replaced.

Public Act 19-120: The agency was previously cited for failing to complete out-of-state background checks on five new employees, as documented in the 6/24/25 field inspection report by Consultant Tom Cuchara. Licensing has continued to monitor the personnel process, and one employee still lacks the required out-of-state background check request. The agency must ensure that HR has a system in place to request and complete out-of-state background checks for any applicant who has lived out of state within the past five years, prior to hire, as required by statute

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                         December 4, 2025
Regulatory Consultant                                           Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|


summary: Visit conducted on _____7/22/2025_________. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Fairfield GH __________

TIME OF VISIT (FROM - TO):       __12:45pm-1pm               DATE: _____7/22/2025_________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Administrator
	Regulatory Consultant-DCF

    List of Areas / Topics covered during visit:

•	Announced visit to group home.
•	Purpose of visit to introduce Regulatory Consultant, Penny Woodward
•	LBC 6.  Census is 4. 3 female and 1male.
•	Staff vacancies
o	Saturday and Sunday 6am - 2pm
o	Sunday, Monday, Tuesday 3pm -11pm; hired and waiting for start date
•	Program driveway is in poor condition with numerous potholes and pavement lifted due to frost heave.  Program reports it has notified management and seeking a resolution.  Program is in process of getting quotes.
•	The walkway leading to the house has lose bricks(soldiers).  Amanda will get the handyman to repair.

Corrective Actions implemented as a result of previous visit:
Completed.

Areas of regulatory non-compliance identified during this visit:
No RCP Required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara,                                    7/22/2025
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: No RCP Required.


summary: Visit conducted on _____6/6/2025__________. Visit covered 8 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Fairfield GH __________

TIME OF VISIT (FROM - TO):       __9:30m to 11:00am               DATE: _____6/6/2025__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Administrator
	OPCC Director

    List of Areas / Topics covered during visit:

•	LBC 6.  Census is 6.  4 female and 2 males.  Youth observed working with staff on school homework/tutoring.
•	Spoke with new Program Administrator about program and its challenges.
•	Staffing- no concern.
•	Physical Plant: No concern.
•	Reviewed 2 cases for ICPC compliance. No concern.
•	Sprinkler system had a minor leak in the basement which was in the process being repaired at the time of the visit.
•	Program driveway is in poor condition with numerous potholes and pavement lifted due to frost heave.  Program reports it has notified management and seeking a resolution.

Corrective Actions implemented as a result of previous visit:
Completed.

Areas of regulatory non-compliance identified during this visit:
No RCP Required.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara,                                    6/25/205
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: No RCP Required.

personnel:
Program Administrator
OPCC Director


raw_content:
John Peloquin, CEO							3/3/2025
Discovery Practice Management
4281 Katella Avenue, Suite #111
Los Alamitos, CA  90720

Re: Licensing Inspection for Fairfield GH
Regulatory Consultants: Tom Cuchara, Keith Bryan and Pat Hughes

Dear Mr. Peloquin,

On 1/21/25, 1/22/25 and 1/23/25 a biennial re-licensing inspection was conducted at 615 Mine Hill Road, Fairfield, CT.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Regulatory Compliance Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit Regulatory Compliance Plan as well.

Out of State CPS check: No evidence of CPS check request found in file for the following employee- M.M.D.

DCF Reg: 17a145-75 (d) and 17a -6(g) - 16 (c)
Evidence: Based on the review of the Policy and Procedure there is no evidence the medical policy and procedure was reviewed by physician and RN.  LPNs completing admission assessments and initiating nursing care plans. Youth admitted since 12/19/2024 and initial/comprehensive care plan still not established as of 1/23/25. A review of program's admission policy identified that a Registered Nurse is required to complete admission within 24 hours of intake. Program did not follow their own Admission policy either.

Section 17a-145-93. Medical, dental, and nursing care.
Evidence:  Evidence: A review of 6 of 6 clinical records failed to identify Youths' immunization records, 6 of 6 records reviewed failed to identify Youths completed physical assessment based on EPSDT standards, dental and eye care record.

Section 17a-145-98. Case records.
Evidence: Four client files reviewed specifically for ICPC documentation.
Out of state client files reviewed did not find documentation the ICPC form was submitted prior to admission.

Sec. 20-87a. Definitions. Scope of practice.
Evidence:  A review of all 6 client files found the admission and other nursing activities were being completed by the LPN without the direction/supervision of an RN or APRN on site.

Once licensing has reviewed and accepted the Service Development Plan and has determined that your agency is in compliance with the regulations a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision the current license will remain in effect.

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (203) 675-6975.

Sincerely,

Thomas S. Cuchara

Thomas S. Cuchara
Regulatory Consultant

Copy: file|


summary: Visit conducted on _____12/3/24__________. Visit covered 9 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Fairfield GH __________

TIME OF VISIT (FROM - TO):       __9:45am to 11:45am               DATE: _____12/3/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	PD
	Milieu Manager

    List of Areas / Topics covered during visit:

•	LBC 6.  Census is 6.  3 female and 3 males.  Age range between 13-16 years old.  Youth were working with staff on school homework/tutoring.
•	Staffing- One vacant 1st shift position.  One vacant 2nd shift position.  One parttime staff starting on 3rd shift 12/9/24.
•	Reviewed citation from last quarterly.  See below.
•	Program lost their RN in September and it has not been filled.  Agency hired a temp agency RN to provide RN responsibilities.
•	Physical Plant: No concern.
•	Reviewed controlled medication count. No concern.  In addition, reviewed storage process of non -controlled medication to be destroyed. The program will reach out to the local pharmacy, Consumer Protection and DPH for guidance.

Corrective Actions implemented as a result of previous visit:
Completed.
Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines, and instruments. Sick room, telephone.
d) The facility shall permit only staff who have been fully instructed in the proper administration, expected and untoward effects, and contraindications to continue administration of a prescribed medicine or treatment to administer that medicine or treatment. The facility shall have a written policy specifying the criteria used for designating staff to administer medication and a written plan for training staff. The facility shall maintain a current, written roster of staff designated to administer medication. There shall be periodic reviews and updating of staff's knowledge about medication and other treatments and their administration.

Evidence:
At the time of the licensing visit, the RN Administrator on duty had possession of the med keys.  Upon review of the medication key exchange book, there is no evidence of a key exchange taking place between the RN and the assigned medication certified staff.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-76. Kitchen, equipment, food handling.
Evidence: The basement freezer needs to be defrosted.
Physical plant: The casement window in the basement is broken and does not close.  It should be repaired
or replaced.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara,                                    12/24/24
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

personnel:
PD
Milieu Manager


summary: Visit conducted on _____6/20/24__________. Visit covered 7 main areas/topics. Found 5 compliance issues. Implemented 1 corrective actions.

raw_content:
DCF-3034
6/2021 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Fairfield GH __________

TIME OF VISIT (FROM - TO):       __10pm to 12:15pm ___               DATE: _____6/20/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	PD
	LPN

List of Areas / Topics covered during visit:

Amended quarterly report for 6/20/24.  The citation regarding improper storage of the medication is removed.  This is not a citation.

•	Census is 6 . 3 female and 3 males.  Age range between 12-17 years old. Milieu is quiet and staff interacting positively with youth.
•	Staffing- One vacant over night shift.  The PD is new and recently promoted to this position.  LPN is on duty.
•	Reviewed citation from last quarterly.  See below.
•	Reviewed RN intake assessment for date it was completed within 72 hours.
•	Physical Plant: At the time of inspection, the 'AC' on second floor was not working.  A service call was made and a service representative arrived to fix the AC.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-61. Written policies and procedures.
Evidence: At the time of the quarterly visit the LPN was conducting routine weekly body checks.  When questioned the LPN indicated there was no clinical reason for a body check and was told it should be done.  On the relicensing visit 2/6/19 and 2/7/19, the agency was cited for completing weekly body checks.  The policy and procedure was revised to complete body checks when medically necessary and completed by the LPN/RN.  The program did not follow the Policy and Procedure.  This is a second citation.

Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines, and instruments. Sick room, telephone.
d) The facility shall permit only staff who have been fully instructed in the proper administration, expected and untoward effects, and contraindications to continue administration of a prescribed medicine or treatment to administer that medicine or treatment. The facility shall have a written policy specifying the criteria used for designating staff to administer medication and a written plan for training staff. The facility shall maintain a current, written roster of staff designated to administer medication. There shall be periodic reviews and updating of staff's knowledge about medication and other treatments and their administration.

Evidence:
•	At the time of the licensing visit, the LPN on duty had possession of the med keys.  Upon review of the medication key exchange book, there is no evidence of a key exchange taken place between the LPN and the assigned medication certified staff.  Additionally, staff continue to sign out the keys at the beginning of the shift.  This is a second citation; staff are instructed to sign out the medication keys at the end of their assigned shift when handing the keys to another medication certified staff member.

Section 17 a-145-93. Medical, dental and nursing care - Health Care Standards of Children and Youth in Care and DPH RN Scope of practice
Evidence: When clients are admitted, the RN is required to complete a nursing assessment within 72 hours.  Six client files were reviewed; three files did not have evidence the RN completed the nursing assessment within 72 hours.

Addendum:  This Regulatory Consultant contacted Errolee Miller, RN DCF Nurse Consultant to assist reviewing the medication process at Fairfield.  Errolee made an unannounced visit, 7/9/24.
Evidence:
•	At the time of the visit the census was 5.  One youth was admitted 7/5/24, but no evidence a nursing assessment was completed.
•	Based on review of Nursing admission assessment of five of five youths and facility's nursing supervisor and LPN/LVN position summary, the program failed to complete nursing admission assessment in a timely manner based on best practices and regulatory recommendations for three of five youths. The facility also allowed an LPN to complete an admission assessment on one of five youths currently at program without RN oversight/supervision.

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Thomas S. Cuchara,                                    7/15/24
Regulatory Consultant                                   Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: When questioned the

area_type: Evidence

personnel: PD LPN