summary: Visit conducted on 7-12-23. 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: The Children's Center of Hamden, Inc. - START (PRTF) Program

TIME OF VISIT (FROM - TO):     9:30am- 1:00pm                 	DATE:  7-12-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
VP, Residential Services
Lifeguard
Nurse (2)
Direct Care Worker/ Brewster Cottage
Direct Care Worker / Heaton Cottage
Direct Care Worker / Marcy Cottage
Male clients

List of Areas / Topics covered during visit:  This was a scheduled quarterly visit to the START program, a psychiatric residential treatment facility (PRTF), to obtain a program update and tour the physical plant.

A meeting was held with the VP of Residential Services who reported on the following:
•	Census: 21 residents (8 females, 13 males). Female admission scheduled for today.
•	Food Services: Cafeteria schedule is lunch only Monday-Friday, other meal deliveries to cottage, take-out dinner on Sundays.
•	Summer school.
•	Summer worker program with Horticulturist.
•	Recreation activities on campus.
•	Anticipated video camera upgrade on campus.
•	Staff vacancies; three direct care workers; one part time nurse.
•	Fencing.
•	Clinical Department: Clinician positions are full; VP of Clinical Services on leave, covered by a licensed clinician administrator.
•	Incident data for the quarter not available.
•	Recent 190th birthday celebration for CCOH.
•	DSS authorization for full capacity of 28 beds.

Physical Plant: The Vice President of Residential Services facilitated a tour of the Brewster, Marcy and Heaton cottages.
•	All interior areas appeared clean and organized.
•	Overgrown vegetation observed at Marcy and Heaton cottages.
•	Stockade fence in rear yard of Marcy has been repainted.
•	Client interviews with male residents in two cottages.
•	Milieu observation.
•	Drinking water available.
•	Discussion on window coverings.

Swimming pool: A tour was conducted of the facility outdoor pool. Topics discussed with Lifeguard on duty included:
•	Several direct care staff present in pool area when clients are in the pool.
•	Swim testing procedures for clients.
•	Pool rescue equipment.
•	Pool water-testing logs.
•	Cell phone and walkie-talkie for communication.
•	Security of pool house.
•	Three Lifeguards cover pool schedule.

Milieu Observation:
•	Medication administration in Brewster.
•	Lunch in male cottages.
•	Outdoor recreation activity.
•	Swimming pool.

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

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:  7-17-23
Regulatory Consultant

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

Cc: 	VP, Residential Services|


state: CT

facility_name: Children's Center of Hamden (The) / START / RT #73

summary: Visit conducted on 6-21-23. Visit covered 1 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: The Children's Center of Hamden, Inc. - START (PRTF) Program

TIME OF VISIT (FROM - TO):     10:30am - 2:00pm                 	DATE:   6-21-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Human Resource Hiring & Training Manager
VP of Human Resources
Chief Development Officer

List of Areas / Topics covered during visit:  This was a scheduled visit to the START program, a psychiatric residential treatment facility (PRTF), to conduct a semi-annual personnel file review for regulatory compliance.

A meeting was held with the Human Resource Hiring & Training Manager and the VP of Human Resources. Topics discussed included:
•	Professional license verification
•	Annual CPR refresher training
•	Physical exam documentation

Eight personnel files were reviewed. 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 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:  6-22-23
Regulatory Consultant

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

Cc:	VP, Residential Services
      VP, Human Resources|


summary: Visit conducted on 4-27-23. 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: The Children's Center of Hamden, Inc. - START (PRTF) Program

TIME OF VISIT (FROM - TO):     10:00am - 1:50pm                 	DATE: 4-27-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
VP of Residential Services
Chief Executive Officer
Client (male)
VP of Human Resources
Director of Human Resources

List of Areas / Topics covered during visit:  This was a scheduled visit to the START program, a psychiatric residential treatment facility (PRTF), to tour the physical plant and obtain a program update.

A meeting was held with the Vice President of Residential Services and VP President of Human Resources. Topics discussed included:
•	Census = 24 (9 females, 15 males)
•	Staff Vacancies (4 direct care workers, 2 nursing positions); all clinician positions are filled
•	Nursing coverage for the PRTF
•	Length of stay in the PRTF for some residents
•	New Director of Human Resources
•	New Principal in the education program
•	Recent successful Joint Commission triennial survey
•	Staff appreciation activities
•	Increased communication with staff and administration; Quarterly 'All Staff' meetings; Monthly staff/CEO lunches
•	On-site psychiatrist activities
•	Review of incident data report for the quarter

Meeting held with VP of Residential Services and CEO. Topics discussed included:
•	Investigations
•	Proposed subacute program at CCOH; possible renovations for ADA compliance
•	Emergency physical intervention reduction initiative
•	Proposed upgrade to campus fencing; proposed gate at main entrance
•	Emergency physical intervention data reflects an increase due to DPH new category ('restriction of movement')

VP of Residential Services facilitated a tour of the three PRTF cottages.
•	All areas appeared very clean and well organized.

Case record Review - One client record reviewed for regulatory compliance and PRTF Standards compliance.
Corrective Actions implemented as a result of previous visit: N/A

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:   5-2-23
Regulatory Consultant

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

Cc: VP, Residential Services|


summary: Visit conducted on 1-5-23. Visit covered 3 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: The Children's Center of Hamden, Inc. (CCOH) - START/PRTF Program

TIME OF VISIT (FROM - TO):    10:00am-12:30pm                             DATE: 1-5-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Chief Development Officer
Vice President, Residential Services
Vice President, Clinical Services
Director of Residential Services
Food Services Workers
Client

List of Areas / Topics covered during visit: At the request of CCOH, a scheduled meeting was held onsite with three agency administrators to tour physical plant space for a proposed new co-ed eight bed program. The Chief Development Officer reported that CCOH was contacted by DCF to consider opening the sub-acute portion of an urgent care center. It was reported that an agreement has been made between Yale New Haven Hospital and CCOH to serve children in need of short term residential care when discharging from the hospital Emergency Department. The space is located in Wakeman Hall on the first floor and contains numerous rooms to be used for bedrooms, a kitchen, offices, and two lounges. Two full bathrooms are housed in the space, one of which is ADA compliant. Clinical services and staffing ratios were discussed. Renovation plans were discussed (addition of fire sprinklers, nursing office, kitchen, adding a ramp at a rear exit, ligature-risk assessment, consultation with the fire marshal regarding emergency exits, etc.). Discussion held on bedroom size requirements listed in the child caring facility regulations. It was reported that CCOH is still considering DCF's request and may move forward with submitting a proposal to the Department.

An unscheduled visit was conducted at the START/PRTF program with the Vice President of Residential Services and the Director of Residential Services. Topics discussed included:
•	Current census in the START program is at 16 (9 females, 7 males)
•	Female client in the program for more than one year
•	Provider meeting scheduled for this date to discuss a male client currently hospitalized
•	Average length of stay for clients in the PRTF
•	Supervisory coverage seven days per week
•	Recent holiday activities
•	Meals for the PRTF program continue to be served in the cottages instead of the Cafeteria, with the exception of lunch on school days
•	Storage of dry goods in cottage kitchens
•	New game room scheduled to open
•	Client incidents
•	Recent COVID cases among clients and staff; mask requirement for cottage staff has remained in place since start of pandemic
•	Staffing vacancies (3 direct care workers, two nurses, 3 clinicians)
•	CEO monthly lunch meetings with staff
•	Unannounced visits from DPH
•	Physical plant tour of Brewster and Marcy cottages. All appears appeared very clean and organized. Heaton cottage was not observed due to a client on quarantine status due to testing positive for COVID.

The Cafeteria was observed during the lunch period:
•	Lunch served this day consisted of pesto chicken pasta, minestrone soup, garden salad, milk (including chocolate and lactose-free) and choice of three fresh fruits.
•	Four kitchen workers were on duty along with a paid client worker in the dish room.
•	The client was interviewed, and no complaints were reported.
•	Observed lunch being served to day school students and the PRTF residents. Numerous school staff and supervisors were observed eating lunch with students throughout the Cafeteria.
•	When asked, a food services worker reported that there was one staff opening in the Kitchen.

Corrective Actions implemented as a result of previous visit:
•	A service development plan submitted by The Children's Center of Hamden following a November 2022 Licensing visit that addressed regulatory citations in relation to staff training documentation for CPR and restraint. The plan was accepted by the Department.

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

Kathleen Forsythe, LCSW      		Date:     1-6-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc:	VP, Residential Services
Chief Development Officer|


summary: Visit conducted on 11-17-22. 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: The Children's Center of Hamden, Inc. (TCCOH) - START/PRTF Program

TIME OF VISIT (FROM - TO):    9:30am - 1:30pm                             DATE: 11-17-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Director of Human Resources
Human Resources Coordinator
Training & Hiring Manager
VP of Support Services
Culinary Arts Teacher
Education Director
Client

List of Areas / Topics covered during visit: This was a scheduled Licensing visit to conduct a semiannual personnel file review, as well as to review training records for staff affiliated with the psychiatric residential treatment facility (PRTF) for standards compliance.

Personnel file review:
•	Two personnel files of recently hired staff were reviewed. See 'Areas of Regulatory Non-Compliance' below.

PRTF staff training records review:
•	Employee restraint and CPR training documentation for 2022 for the PRTF program was reviewed.
•	Agency switched restraint training programs in the Fall of 2022 from CPI (Crisis Prevention Institute) to CCG (Crisis Consulting Group).
•	Ten employees attended a CCG 'train the trainer' session on 8-31-22.
•	Training documentation for 66 employees in the PRTF (psychiatric residential treatment facility) program was reviewed. PRTF standards require semiannual restraint refresher training and annual CPR training. See 'Areas of Regulatory Non-Compliance' below.

Staff Appreciation Event:
•	Luncheon held during visit for employee appreciation.
•	Observation of agency's new wood-fired pizza oven trailer in operation.
•	Interview with client learning vocation skills.
•	Interviews with Culinary Arts Teacher and Director of Education.

Corrective Actions implemented as a result of previous visit:
•	A service development plan submitted by The Children's Center of Hamden following an October 2022 Licensing visit that addressed regulatory citations in relation to cottage kitchens was accepted by the Department.

Areas of regulatory non-compliance identified during this visit:
1.	The results of a criminal history background check and the results of a child protective services background check for one employee are dated after the employee's hire date rather than prior to hire.
2.	Documentation of semiannual restraint training was not found for six employees as required by §483.3 76(f). Staff must demonstrate their competencies as specified in paragraph (a) of this section on a semiannual basis and their competencies as specified in paragraph (b) of this section on an annual basis", listed under 483.376 Education and Training in Appendix N- State Operations Manual for Psychiatric Residential Treatment Facilities (PRTF) Interpretive Guidance from the Center for Medicare & Medicaid Services.
3.	No evidence was found in files reviewed that any PRTF staff have been trained annually in CPR as required by §483.376(b)
4.	No evidence was found that one perdiem nurse has been trained in CPR.
5.	Evidence was found that 42 staff members affiliated with the PRTF have participated in online CPR training only and are not certified in CPR. No evidence was found that these staff completed the hands-on skills demonstration of CPR as required by §483.376(d) "Staff training must include training exercises in which staff members successfully demonstrate in practice the techniques they have learned for managing emergency safety situations."

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.

Kathleen Forsythe, LCSW                              		Date:   11-22-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc:      	VP, Residential Services
            VP, Support Services
            HR Director|

type: general


summary: Visit conducted on 10-6-22. Visit covered 26 main areas/topics. Found 6 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: The Children's Center of Hamden, inc. - START Program

 TIME OF VISIT (FROM - TO):       12:30pm-2:15pm             DATE: 10-6-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Vice President of Residential Services
•	Director of Residential services
•	Brewster Cottage Program Manager
•	Marcy Cottage Program Manager
•	PRTF program Psychiatrist
•	Vice President of Clinical Services
•	Medical APRN

Areas / Topics covered during visit:  This was an unannounced Licensing visit to tour the PRTF cottages and obtain an update on the PRTF program. Topics discussed:
•	Admissions re-opened for the PRTF program earlier this week after follow-up visit from DPH and accepted corrective action plan
•	Current census = 11 (7 males, 4 females) after two females discharged this week
•	Anticipated admission scheduled for 10-11-22
•	Physical plant tour of Brewster, Heaton, and Marcy cottages, as well as Clinic. Cottages contained seasonal décor. Areas in some boys' bedrooms in need of touch-up painting.
•	Scheduled summer/fall events (Fall Carnival, Family Day, acrobat show, football camp, musician classes, cottage bake-off, cottage decoration contest, haircare/barber classes, talent show, etc.)
•	Recreation activities no longer held in the community since Summer 2022
•	Emergency Safety Manager office/Onsite supervisor office moved to the Clinic
•	Meal delivery continues to the cottages; lunch only served in dining hall on school days for PRTF clients; ensuring food safety for meals delivered to cottages
•	Numerous dry goods not stored in sealed containers in Marcy cottage, and Brewster/Heaton rear kitchen
•	Condition of cottage bathroom shower curtains; deteriorated condition of bathroom stalls in boys' cottages
•	Additional storage needed in some bedrooms
•	New TV purchased for Heaton cottage
•	New 'welcome room' in Marcy cottage for new admissions
•	CCOH purchased a pizza truck for weekly pizza day; offers vocational opportunities for some students
•	Weekly outdoor co-ed rec activities on campus
•	Weekly movie nights in Cafeteria
•	Renovations to Marcy bathroom to reduce ligature risk areas
•	Deteriorated fence in Marcy cottage backyard
•	Brief meeting with PRTF Leadership team
•	New PRTF Psychiatrist began duties in August 2022
•	Part-time Psychiatric APRN hired in October for EDT & OPCC programs

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

Areas of regulatory non-compliance identified during this visit:
17a-145-76	Kitchen, Equipment, Food-Handling
•	A refrigerator/freezer in Heaton cottage does not contain thermometers to ensure proper temperatures are maintained.
•	Disposable dishes were not stored in a manner to prevent contamination in Brewster cottage.
•	Perishable food from the breakfast meal was observed on a dining table in Brewster cottage, which does not contain a refrigerator.
•	Numerous dry goods in the Marcy, Brewster and Heaton cottages are not stored in a manner to prevent contamination.

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: 10-7-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: VP of Residential Services|

description: 76 Kitchen, Equipment, Food

description: Handling


summary: Visit conducted on 7-21-22. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
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: The Children's Center of Hamden, Inc.  - START Program

 TIME OF VISIT (FROM - TO):     10:00am - 2:15pm              DATE: 7-21-22

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Chief Development and Engagement Officer
Vice President of Residential Services
HR Director
Lifeguard WJ
Several clients

List of Areas / Topics covered during visit:  This was a scheduled visit to conduct a semi-annual personnel file review and to tour the PRTF cottages.
•	Twenty-one (21) personnel files were reviewed of PRTF staff hired since January 2022.
•	Physical plant tour of the Marcy, Brewster, and Heaton cottages: areas appeared clean and organized
•	Milieu observation in three cottages
•	Client interviews
•	Physical plant tour of the campus swimming pool and interview with Lifeguard on duty re: client swim testing, pool water testing, safety equipment, certifications, staff supervision locations in pool area, availability of drinking water and phone, security of pump house, etc.
•	Meeting with Chief Development and Engagement Officer. Topics discuss:
o	Beacon Healthcare providing consultation resources for the PRTF program effective this month
o	New psychiatrist to start full time in August 2022
o	VP of Clinical Services filled by existing employee
o	All PRTF Clinician positions are filled; VP of Clinical Services covering the Clinical Director position
o	Program Manager assignments/locations in three PRTF cottages
o	Random weekly audits of orientation checklists and supervision notes for skills assessments of new employees
o	Monthly 'Direct Care Worker 101' trainings
o	Revised competency assessments for probationary employees
o	Waiting on the 2567 report from DPH from Spring 2022 recertification process
o	Off campus trip client supervision ratios (1:3); licensed clinicians make determination for client eligibility for off campus rec trips
o	Group sessions held in cottages with clients by nursing staff to discuss neurological protocol for head injuries
o	Use of two temp agency RN's
o	Clinicians providing education for residential managers

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

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

Kathleen Forsythe, LCSW			DATE: 7-25-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc:	 VP of Residential Services
Chief Development and Engagement Officer|


summary: Visit conducted on 6-6-22. Visit covered 9 main areas/topics. No compliance issues identified.

raw_content:
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: The Children's Center of Hamden, Inc. - START/PRTF program

TIME OF VISIT (FROM - TO):       1:30pm-4:00pm              DATE: 6-6-22

AGENCY PERSONNEL WHO PARTICIPATED:
                      Job Titles:
Chief Executive Officer
Chief Operations Officer
Vice President of Residential Services
Director of Residential Services
Vice President of Clinical Services
Quality Assurance/Compliance Coordinator
Lead Environmental Safety Manager/Lifeguard
DCF Regulatory Consultant

List of Areas / Topics covered during visit:  This was an unannounced visit to tour the physical plant of the PRTF cottages and swimming pool area, and, to meet the new CEO.
•	Meeting with new CEO & COO
•	Recent IJ report
•	Consolidation of cottages
•	Census: 19 residents
•	Admissions status
•	Cottage physical plant tour with Residential & Clinical Management, and QA
•	Milieu observation in three PRTF cottages; conversations with residents
•	Food Services discussion with VP of Residential Services
•	Physical Plant tour of campus swimming pool
o	Pool shed
o	Lifeguard and CPR certifications
o	Town of Hamden pool inspection certificate
o	Safety signage
o	Lifesaving equipment
o	Cell phone and two-way radio
o	Swim test logs
o	Pool water testing logs
o	Drinking water availability in pool area

Corrective Actions implemented as a result of previous visit:    Not applicable

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

Kathleen Forsythe, LCSW                                                        				Date: 6-9-22
_______________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: COO
       VP, Residential Services|


summary: Visit conducted on 5-18-22. Visit covered 6 main areas/topics. No compliance issues identified.

raw_content:
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: The Children's Center of Hamden Inc. - START/PRTF Program

TIME OF VISIT (FROM - TO):      1:25pm - 3:40pm               DATE:   5-18-22

AGENCY PERSONNEL WHO PARTICIPATED:

               Job Titles:
Vice President of Clinical Services
Residential Director
Direct Care Workers - 5
Clients - 10 (8 males, 2 females)
Nurse, LPN
Vice President of Residential Services
Interim CEO
Supervisor/Trainer
Compliance/Quality Assurance Coordinator

List of Areas / Topics covered during visit:  This was an unannounced visit to observe the milieu and interview clients.
•	COVID testing and safety protocols
•	Emergency exit testing
•	Meal service
•	Milieu observation
•	Update on DPH activities
•	Physical plant tour of living units (Kids Cottage, Care, Brewster, Heaton cottages)

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

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

Kathleen Forsythe, LCSW                                             5-19-22
______________________________                  _________________
Regulatory Consultant                                                Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: VP, Residential Services
      Interim CEO|


summary: Visit conducted on 5-13-22. Visit covered 8 main areas/topics. No compliance issues identified.

raw_content:
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: The Children's Center of Hamden, Inc. - START (PRTF)                Program

 TIME OF VISIT (FROM - TO):  1:00pm - 5:30pm              DATE:  5-13-22

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title:
CFO/ Interim CEO team
Executive Office Manager
Senior Director of Clinical Services
Female clients (4)
Male client (1)

Areas / Topics covered during visit: This was an unannounced Licensing visit to interview DCF-involved clients.
•	Staff training activities this week
•	DPH corrective action plan
•	Revised EPR policy and form
•	Revised Incident policy and form
•	Incident tracking by Executive Office Manager
•	COVID testing, protocols, etc.
•	Client interviews

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

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

Kathleen Forsythe, LCSW                                            			5-16-22
______________________________            _________________
Regulatory Consultant                                                 Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
cc: VP, Residential Services
      Interim CEO|


facility_name: Village for Families & Children/RT#44/ Eagle House

summary: Visit conducted on June 12, 2025. Visit covered 6 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    9:30 am           DATE:  June 12, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the census; currently there are 24 residents, and the LBC is 28. Currently Eagle House has an extensive wait list.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, recreational activities as well as other activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Discussion of improvements to the buildings and the grounds which are taking place at Eagle House.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                         6/18/25
Regulatory Consultant                                                                Date|


summary: Visit conducted on March 25, 2025. Visit covered 7 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    9:00 am           DATE:  March 25, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the census; currently there are 24 residents, and the LBC is 28. Currently Eagle House has an extensive wait list.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, recreational activities as well as other activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Eagle House residents participating in the Eagle House School program.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

•	An incident response note was completed this quarter on Eagle House.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                          5/25/25
Regulatory Consultant                                                                Date|


summary: Visit conducted on December 17, 2024. Visit covered 6 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    9:00   to 10:30 pm            DATE:  December 17, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 21 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

•	An incident response note was completed this quarter on Eagle House.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                         12/23/24
Regulatory Consultant                                                                Date|

visit_date: December 17, 2024


summary: Visit conducted on September 12, 2024. Visit covered 5 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    9:00   to 10:30 pm                   DATE:  September 12, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 16 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                             9/16/24
Regulatory Consultant                                                                Date|

visit_date: September 12, 2024


raw_content:
July 1, 2024

Hector Glynn, President and Executive Director
Village for Families and Children
1680 Albany Avenue
Hartford, CT 06105

RE: CCF/RT- 44 Eagle House

Dear Mr. Rodriguez,

On May 29th and May 30th, 2024, a biennial licensing inspection was conducted at your facility. 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, the Psychiatric Residential Treatment Facilities Guidelines, and the DCF Guidelines for the Administration of Medication by Certified Staff.

Please review the areas identified and submit the regulatory compliance plan of correction 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 correction(s) will be completed. The areas of non-compliance are as follows:

Regulations for the Operation of Child-Caring Agencies and Facilities

17a-145-73 Sleeping accommodations.
Evidence: The bedroom doors in bedrooms #1 & # 4 in the Brainard Building rub against the floor and have caused scratches and marks to the bedroom floors.
Evidence: The bedroom door in bedrooms #1 in the Goodwin Building rubs against the floor and has caused scratches and marks to the bedroom floor.
Evidence: The top of the staircase leading to Goodwin Building bedroom hallway there is a piece of floorboard loose and sticking up creating a tripping hazard.

17a-145-74 Lavatory facilities. Toilet articles and linens.
Evidence: The large bathroom on the second floor of the Brainard Building has 2 shower stalls that have missing bathroom tile / tiled soap dishes leaving an opening exposing patches of what appears to be old, hardened tile grout.

17a-145-76 Kitchens, equipment, food handling.
Evidence: The cabinet trim is missing from under the stove in the Brainard                     building kitchen.

Psychiatric Residential Treatment Facilities Guidelines

CFR 483.358 Orders for the Use of Restraint or Seclusion.
Evidence: 1 case record had one incident of restraint where the restraint ordered was different from the restraint that was performed. (1-person seated restraint was ordered, a 2-person seated restraint was performed).

CFR 483.370 Post-Intervention Debriefings.
Evidence: In 5 case records involving 7 physical restraints there is no evidence a debriefing between the staff and the resident occurred.
Evidence: In 1 case record there were 2 restraints where the staff / client debriefing was late (more than 24 hours from the time of the restraint).
Evidence: In 4 case records there were 15 restraints where the staff and supervisory debriefing was late (more than 24 from the time of the restraint).

Once the licensing unit has reviewed and accepted your plan of correction and has determined that your agency is in compliance with the regulations a decision will be made regarding the issuance of a regular 24-month license.  Until the Department renders a decision your current license will remain in effect.

Sincerely,
Patrick Hughes

Patrick Hughes
DCF Licensing Unit
860-550-6552p 860-716-2199c
patrick.hughes@ct.gov|

report_type: unstructured


summary: Visit conducted on March 28, 2024. Visit covered 5 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    10:00   to 11:30 pm                   DATE:  March 28, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 21 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                             4/1/24
Regulatory Consultant                                                                Date|


summary: Visit conducted on December 14, 2023. Visit covered 6 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    9:45 am   to 11:30 pm                   DATE:  December 14, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 23 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Eagle House residents and the interactions between the residents and Eagle House staff.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                          12/22/23
Regulatory Consultant                                                                Date|

visit_date: December 14, 2023


summary: Visit conducted on September 14, 2023. Visit covered 5 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    11:00 am   to 12:30 pm                   DATE:  September 14, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 19 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                             9/14/23
Regulatory Consultant                                                                Date|

visit_date: September 14, 2023


summary: Visit conducted on May 31, 2023. Visit covered 5 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    10:00 am   to 11:30 am                   DATE:  May 31, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 21 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                               5/31/23
Regulatory Consultant                                                                Date|


summary: Visit conducted on March 28, 2023. Visit covered 5 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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    10:00 am   to 11:30 am                   DATE:  March 28, 2023

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Senior Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census; there are 20 residents, and the LBC is 28.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Observations of the Eagle House residents and observations of the interactions between Eagle House staff and the Eagle House residents.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes
Regulatory Consultant                                                                Date             3/28/23|


summary: Visit conducted on December 19, 2022. Visit covered 1 main areas/topics. No compliance issues identified.

raw_content:
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:    The Village for Families and Children / Eagle House

TIME OF VISIT (FROM - TO):    10:00 am                     DATE:  December 19, 2022

AGENCY PERSONNEL WHO PARTICIPATED:
Eagle House Program Director

List of Areas / Topics covered during visit:

Census
The current census for Eagle House is 20 and the licensed bed capacity is 28.
One resident is currently hospitalized but is expected to return soon.
Eagle House has seen a slowdown in referrals as of late.

Discussion of the residents' progress in the program and the program's milieu.
The residents are doing well at Eagle House with incidents and physical holds having
decreased over the last few months.  Most of the Eagle residents will visit home on Christmas either for the day or overnight. There are several residents that are on discharge delay due to adoption disruptions, unstable housing for some families.

During the quarterly visit this regulatory consultant had planned to walk through the school building to observe the school day in progress. As this regulatory consultant approached the entrance there was a student in crisis at the entrance. The student was being supported by staff and the staff were attempting to deescalate the situation. As a result of the situation at the entrance this regulatory consultant opted to forego the school walk through until the next quarterly visit.

Discussion of current staffing levels and hiring of vacant positions.
Eagle House has created a clinical case manager position who will be responsible for insurance approvals, authorizations, and commercial insurance approvals. There is a large group of Eagle House new hires that will start on January 9th. There are still vacant direct care positions, mostly for 1st shift and weekend positions. The Village is offering bonuses for weekend shift positions. Eagle House can fill any vacant shifts with the use of per-diem staff, supervisors, and overtime for current workers.

Physical plant inspection of the facility.
All areas of the program were clean and organized with no health or safety concerns observed.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                               2/23/2023
Regulatory Consultant                                   Date|

visit_date: December 19, 2022


summary: Visit conducted on September 15, 2022. Visit covered 2 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:    The Village for Families and Children / Eagle House

 TIME OF VISIT (FROM - TO):    2:00 pm                     DATE:  September 15, 2022

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
JT              	Eagle House Program Director

List of Areas / Topics covered during visit:

The current census for Eagle House is 21 and the licensed bed capacity is 28.
There have been several recent discharges at Eagle House.
There has been a slow down in referrals as of late, and there has been a shift in referrals
with an increase of the number of referrals for 11- and 12-year-olds.

Discussion of the residents' progress in the program and the program's milieu.
The residents are doing well at Eagle House with incidents and physical holds having
decreased over the last few months. The Eagle House residents are assigned into groups of 6
for treatment and activities. There are volunteers working on beautification projects at Eagle House painting murals and making the environment more child friendly.

Discussion of current staffing levels and hiring of vacant positions.
Eagle House has hired a Milieu Operations Director, who is responsible for overseeing and supervising the Eagle House supervisors.  There is also a Milieu Administrator to be filled.  This position will be responsible for equipment, environmental safety, payroll and documentation, and safety checks. There are some current vacancies for full time and part time staff. Eagle House can fill any vacant shifts with per-diem staff.

Physical plant inspection of the facility.
All areas of the program were clean and organized with no health or safety concerns observed.
New items have been added to the residents' game room. Construction of permanent fencing around the campus will begin in spring of 2023.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                               10/28/2022
Regulatory Consultant                                   Date|

visit_date: September 15, 2022

personnel: JT              	Eagle House Program Director


raw_content:
August 24, 2022

Gallo A. Rodriquez, Executive Director
Village for Families and Children
1680 Albany Avenue
Hartford, CT 06105

RE: CCF/RT-44 Eagle House

Dear Mr. Rodriguez,

On August 23, 2022 we received your agency's service development plan. The plan submitted by you addresses the areas of non-compliance identified in the inspection report. This inspection included the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, the Psychiatric Residential Treatment Facilities Guidelines and the DCF Guidelines for the Administration of Medication by Certified Staff. The Department accepts the plan of correction and has determined that your agency has met the requirements for a regular license. This license is effective as of August 1, 2022 and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process.

Sincerely,
Patrick Hughes

Patrick Hughes
Department of Children and Families
505 Hudson Street
Hartford, CT  06106
(p) 860-550-6552
(f) 860-550-6665
patrick.hughes@ct.gov|


raw_content:
July 22, 2022

Gallo A. Rodriquez, Executive Director
Village for Families and Children
1680 Albany Avenue
Hartford, CT 06105

RE: CCF/RT-44 Eagle House

Dear Mr. Rodriguez,

On June 22nd and June 23rd, 2022, a biennial licensing inspection was conducted at your facility. 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, the Psychiatric Residential Treatment Facilities Guidelines, and the DCF Guidelines for the Administration of Medication by Certified Staff.

Please review the areas of non-compliance identified on the enclosed Service Development Plans (part 1 and part 2) and submit your responses on the enclosed Service Development Plans 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 Service Development Plan.

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.

Sincerely,

Patrick Hughes

Patrick Hughes
DCF Licensing Unit
860-550-6552
860-716-2199 (cell)
patrick.hughes@ct.gov

DCF LICENSING UNIT
INSPECTION REPORT

Date of Licensing Visit:

June 22nd & 23rd , 2022	Date Licensing Report Received by Facility:
7/25/22	License Type:

CCF	License No. #:

CCF # 44	Date Service Development Plan Submitted to Licensing Unit:

Corporate Name:
Village for Families and Children	Corporate Address:
1680 Albany Avenue, Hartford, CT

Program Name:
Eagle House	Program Address:
1680 Albany Avenue, Hartford, CT

Person Submitting Plan (Name and Title):
	Person Approving Plan (Name and Title):
	Date:

Regulations for the Operation of Child-Caring Agencies and Facilities
  Statute/
Licensing
Regulation #	Non-Compliance Citation	Plan of Correction/Service Development Plan	A System to Prevent
Re-Occurrence	Completion Date	Title Responsible to Monitor Plan
17a-145-73
Sleeping Accommodations

	Brainard Building.
Bedroom # 5's Window   Frame is bent which prevents the window from completely closing.

Brainard Building.
The Bedroom Hallway Flooring is peeling, has divots and has a missing piece of planking. A plan with a time frame to repair the flooring needs to be developed.

Brainard Building
The bedroom Hallway Exit Door has a crack in the window.

DCF LICENSING UNIT
INSPECTION REPORT

Date of Licensing Visit:

June 22 & 23, 2022	Date Licensing Report Received by Facility:
7/25/22	License Type:

CCF	License No. #:

CCF #44	Date Service Development Plan Submitted to Licensing Unit:
8.23.2022

Corporate Name:
Village for Families and Children	Corporate Address:
1680 Albany Avenue, Hartford, CT

Program Name:
Eagle House	Program Address:
1680 Albany Avenue, Hartford, CT

Person Submitting Plan (Name and Title):
Jennifer Timreck, LCSW, Senior Program Director 	Person Approving Plan (Name and Title):
Hector Glenn, MSW Chief Operating Officer   	Date:
8.23.2022

Psychiatric Residential Treatment Facilities Guidelines

  Statute/
Licensing
Regulation #	Non-Compliance Citation	Plan of Correction/Service Development Plan	A System to Prevent
Re-Occurrence	Completion Date	Title Responsible to Monitor Plan

42 CFR 483.358 Orders for the Use of Restraint or Seclusion

42 CFR 483.370 Post-Intervention Debriefings

42 CFR 483.360 Consultation with Treatment Team Physician

# 13 Two case records reviewed had an order for physical restraint that was not signed by the ordering physician.

# 15 One case record reviewed had an order for physical restraint that was not signed in a timely manner by the ordering physician.

One case record contained a physical restraint in which the  staff debriefing occurred more than 24 hours after the restraint.

One case record contained one physical restraint where the consultation between the ordering licensed practitioner and the treatment team physician did not occur.
This was a technical issue in the Carelogic system. The hold orders were being routed to the medical provider Andrea Cronin, APRN however the system was routing the hold order automatically to another person for both of these cases. The issue was reported to IT/Carelogic on 6/21/22 and has been rectified.

Policy will be updated with the following: Hold orders will be signed by the MD as soon as possible, preferably within 24 hours, but no later than 3 days.

Staff retraining on policy and procedure for staff debriefing in July- August 2022 staff meeting.

Medical Director will re-educate medical providers on required documentation for consultation.

The issue was reported to IT/Carelogic on 6/21/22  and has been rectified.

Periodic sample reviews of hold orders. Policy review and reminders at staff meeting.

Weekly reports of missing staff debrief forms are pulled directly from the electronic health record and reviewed by supervisors.

Medical Director will develop a checklist for ordering practitioners to use when ordering holds.

Completed 6/21/2022

8/24/22

8/24/22

8/31/22

Jennifer Timreck, LCSW

Laine Taylor, D.O., M.B.A

Jennifer Timreck, LCSW

Laine Taylor, D.O., M.B.A|


summary: Visit conducted on June 12, 2025. Visit covered 14 main areas/topics. 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:    The Village for Families and Children / Sub Acute (SACS)

TIME OF VISIT (FROM - TO):   11:30 pm                   DATE: June 12, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Sub-Acute (SACS) Program Director

List of Areas / Topics covered during visit:
•	Discussion of the current census, which is 4, and the LBC is 12.

•	Discussion of The Village Sub-Acute program's current staffing levels, vacant positions, and hiring activities. The Village Sub-Acute program is still trying to hire a clinician in order to open the second building.

•	Discussion of The Village Sub-Acute program's milieu, the clinical programming, and activities for the residents.

•	Discussion regarding the upcoming opening of the 2nd Village Sub-Acute building.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Village Sub-Acute program residents and the interactions between the residents and The Village Sub-Acute program staff.

•	Inspection of the Village Sub-Acute program physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.
Corrective Actions implemented as a result of previous visit:
None at the time of this quarterly visit.

Areas of regulatory non-compliance identified during this visit:
17a-145-74: Lavatory facilities. Toilet articles and linens.
Evidence: The upstairs bathroom ceiling has chipped and peeling paint and black stains that appear to be mold and needs to be addressed.

Patrick Hughes                                               6/12/25|

description: Patrick Hughes 6/12/25|


summary: Visit conducted on March 21, 2025. Visit covered 13 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:    The Village for Families and Children / Sub Acute (SACS)

TIME OF VISIT (FROM - TO):   2:15 pm                   DATE: March 21, 2025

AGENCY PERSONNEL WHO PARTICIPATED:
Sub-Acute (SACS) Program Director

List of Areas / Topics covered during visit:
•	Discussion of the current census, which is 5, and the LBC is 5.  There is a wait list and next admission scheduled for 4/12/25.

•	Discussion of The Village Sub-Acute program's current staffing levels, vacant positions, and hiring activities.

•	Discussion of The Village Sub-Acute program's milieu, the clinical programming, and activities for the residents.

•	Discussion regarding the upcoming opening of the 2nd Village Sub-Acute building.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Village Sub-Acute program residents and the interactions between the residents and The Village Sub-Acute program staff.

•	Inspection of the Village Sub-Acute program physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                                                         3/25/25
Regulatory Consultant                                                                Date|


summary: Visit conducted on December 13, 2024. 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:    The Village for Families and Children / Sub Acute (SACS)

TIME OF VISIT (FROM - TO):   2:30 pm                   DATE: December 13, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Sub-Acute (SACS) Program Director

List of Areas / Topics covered during visit:
•	Discussion of the current census, which is 3, and the LBC is 5.  There is an admission scheduled for 12/19/24.

•	Discussion of The Village Sub-Acute program's current staffing levels, vacant positions, and hiring activities.

•	Discussion of The Village Sub-Acute program's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Village Sub-Acute program residents and the interactions between the residents and The Village Sub-Acute program staff.

•	Inspection of the Village Sub-Acute program physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                               12/19/24
Regulatory Consultant                                      Date|

visit_date: December 13, 2024


summary: Visit conducted on July 17, 2024. Visit covered 14 main areas/topics. No compliance issues identified.

raw_content:
CF-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:    The Village for Families and Children / Sub Acute (SACS)

TIME OF VISIT (FROM - TO):   1:30 pm                   DATE:  July 17, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Sub-Acute (SACS) Program Director

List of Areas / Topics covered during visit:
•	Discussion of the current census, which is 4, and the LBC is 5.  One (1) resident is currently hospitalized.

•	Discussion of The Village Sub-Acute program's current staffing levels, vacant positions, and hiring activities.

•	Discussion of The Village Sub-Acute program's milieu, the clinical programming, and activities for the residents.

•	Discussion with the Village Sub-Acute program's leadership regarding the expected opening of the 2nd building for the Village Sub-Acute program.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Village Sub-Acute program residents and the interactions between the residents and The Village Sub-Acute program staff.

•	Inspection of the Village Sub-Acute program physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                               7/18/24|


summary: Visit conducted on June 17, 2024. Visit covered 14 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:    The Village for Families and Children / Sub Acute (SACS)

TIME OF VISIT (FROM - TO):   12:00 pm                   DATE:  June 17, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Vice President of Residential Services
Sub-Acute (SACS) Program Director

List of Areas / Topics covered during visit:
•	Discussion of the current census, which is 4, and the LBC is 5.

•	Discussion of The Village Sub-Acute program's current staffing levels, vacant positions, and hiring activities.

•	Discussion of The Village Sub-Acute program's milieu, the clinical programming, and activities for the residents.

•	Discussion with the Village Sub-Acute program's leadership regarding the expected opening of the 2nd building for the Village Sub-Acute program.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Village Sub-Acute program residents and the interactions between the residents and The Village Sub-Acute program staff.

•	Inspection of the Village Sub-Acute program physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.
Patrick Hughes                                                                               7/1/24
Regulatory Consultant                                                                Date|


summary: Visit covered 6 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:    The Village for Families and Children / Sub Acute (SACS)

TIME OF VISIT (FROM - TO):                      DATE:  February 7, 2024

AGENCY PERSONNEL WHO PARTICIPATED:
Vice President of Residential Services
Sub-Acute (SACS) Program Director

List of Areas / Topics covered during visit:

•	Discussion of the current census, which is 4 residents, and the LBC is 5.

•	Discussion of Eagle House's current staffing levels, vacant positions, and hiring activities.

•	Discussion of Eagle House's milieu, the clinical programming, and activities for the residents.

•	Discussion of recent incidents and behavior trends.

•	Observations of the Eagle House residents and the interactions between the residents and Eagle House staff.

•	Inspection of the Eagle House physical plant to assess the cleanliness of the buildings, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:
Not applicable

Areas of regulatory non-compliance identified during this visit:
None at the time of this quarterly visit.

Patrick Hughes                                               2/7/24|


facility_name: CT Clincal Services DBA Turnbdridge

summary: Visit conducted on 12/17/25. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 12/17/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Director of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Eight female youth were residing at the home currently and all were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 11 clinicians, 12 support staff, 1 clinical director, 1 director of operations, 6 case managers, 4 kitchen staff, 2 nurses and 2 equine staff. There were no available staff positions at the facility.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     12/17/25
Regulatory Consultant                                   Date

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

facility_name: CT Clinical Services / Turnbridge 79 RT

visit_time: First


summary: Visit conducted on 08/27/25. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 08/27/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Director of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Eight female youth were residing at the home currently and all were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 11 clinicians, 10 support staff, 1 clinical director, 3 care team directors, 3 clinical resident liaison, 2 resident liaisons, 2 discharge planners, 4 academic advisors, 4 kitchen staff and 2 nurses. There were also 2 equine staff on duty.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     08/27/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on 06/13/25. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 06/13/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Director of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Eight female youth were residing at the home currently and all were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 4 clinicians, 9 support staff, 1 support staff manger, 1 clinical director, 3 care team directors, 1 resident liaison, 4 kitchen staff, 2 nurses and 2 equine staff.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     06/13/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on 02/07/25. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 02/07/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Director of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. A new bedroom was inspected as the provider increases the LBC from 7 to 8 female residents aa of 2/11/25. Seven female youth were residing at the home currently and all were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 5 clinicians, 8 support staff, 2 program managers, 2 program directors, 3 care team directors, 2 discharge planners, 4 nurses, 1 APRN, 1 doctor, 4 kitchen staff and 2 equine staff.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     02/07/25
Regulatory Consultant                                   Date

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


summary: Visit conducted on 12/13/24. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 12/13/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Director of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Seven female youth were residing at the home. All were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 4 clinicians, 8 support staff, 1 supervisor, 2 discharge planners, 4 nurses, 3 kitchen staff and 2 equine staff.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     12/13/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on 09/30/24. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 09/30/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Vice President of Residential Services
Director of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Six female youth were residing at the home. All were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 5 clinicians, 5 support staff, 3 care team directors, 2 discharge planners, 3 nurses and 2 equine staff.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     09/30/24
Regulatory Consultant                                   Date

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


raw_content:
July 5, 2024

Connecticut Clinical Services, Inc.
DBA Turnbridge
189 Orange Street
New Haven, CT 06510
Attention: Brett Tiberio, President

Regarding Licensing Inspection for CT Clinical Services / 79 Turnbridge RTC:
Inspector Keith Bryan and James Funaro

Dear Mr. Tiberio
On 6/13/24 and 6/14/24 a biennial licensing inspection was conducted at your facility. This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child Caring Agencies and Facilities Sections 17a-145-48 through 17a-151-98, as well as the DCF Guidelines for the Administration of Medication for Certified Staff. DCF has determined that the program is in compliance with all applicable regulatory provisions except those itemized below. Please review the sections identified and submit a plan of correction 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 areas of non-compliance; 2. the date correction(s) will be completed; and 3. plan to prevent recurrence of the citation(s). The areas of non-compliance are as follows:
There are no areas of noncompliance, but there is a recommendation below.
Section 17a-145-94. Written treatment plan
An individualized facility written treatment plan shall be established by the facility and implemented for each child in accordance with department treatment plans and regulations as applicable.
•	It is recommended that the provider have clients and a parent or guardian sign the initial treatment plan.

Once a finding is made that your agency has satisfactorily addressed the regulatory compliance issues, DCF will be prepared to renew your agency’s license.

Please take note that failure to submit an acceptable plan of correction or to successfully implement a plan will result in a licensing action being taken against your agency, including but not limited to suspension and / or non-renewal.

Any questions, comments or concerns you have regarding these findings should be addressed to this Department. Your response will become part of the permanent record of your organization.

Sincerely,

Keith Bryan
DCF Regulatory Consultant
Department of Children and Families
505 Hudson Street
Hartford, CT 06106
Phone: 860-560-5050
Fax: 860-550-6665
keith.bryan@ct.gov
cc: Kathleen DiTuccio, Program Supervisor, DCF-TSS
file|


summary: Visit conducted on 04/25/24. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 04/25/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Vice President of Residential Services

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Six female youth were residing at the home. All were in school at 63 Turnbridge.

On duty at 63 Turnbridge were 6 clinical staff, including the vice president of clinical services, 3 nurses, 10 direct care staff and 1 support staff supervisor. Further, on duty were 4 administrative staff and 5 kitchen staff, including the kitchen manager.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     04/25/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on 03/22/24. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 03/22/24

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Residential Supervisor

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Six female youth were residing at the home. All were in school at 63 Turnbridge. The results of the review of personnel of files will be attached to this report on a later date.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     03/22/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on 12/20/23. No compliance issues identified.

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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 12/20/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Program Managers (2)

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Six female youth were residing at the home. All were in school at 65 Turnbridge.

There were 2 support staff on duty.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                     12/20/23
Regulatory Consultant                                   Date

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


summary: Visit conducted on 09/14/23. No compliance issues identified.

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: CT Clinical Services / Turnbridge 65 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 09/14/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Vice President of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. 10 female youth were residing at the home. The youth were all in school or a session.

On duty were 5 clinicians, clinical director, 1 nurse, 18 direct care staff and two kitchen staff.

Corrective Actions implemented as a result of previous visit:
None

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

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.

Keith Bryan______                                  09/14/23
Regulatory Consultant                                   Date

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

facility_name: CT Clinical Services / Turnbridge 65 RT


summary: Visit conducted on 6/30/23. Found 3 compliance issues. Implemented 2 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: CT Clinical Services / Turnbridge 79 RT

 TIME OF VISIT (FROM - TO):    First Shift               DATE: 6/30/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Vice President of Operations

List of Areas / Topics covered during visit:
Covered the status of the home and the physical plant. Six female youth were residing at the home. All were in a group session at the home as there was an administrative event at 65 Turnbridge.

There were 3 direct care staff on duty and 1 clinician.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-76. Kitchens, equipment, food-handling

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-76. Kitchens, equipment, food-handling
All kitchens shall be clean, well lighted, properly ventilated and screened, and provided with essential and proper equipment for the preparation and serving of food. Storage, refrigeration and freezer facilities shall be adequate for the number of persons to be served. All perishable foods shall be refrigerated at a temperature at or below 45° Fahrenheit. Freezers and frozen food compartments shall be maintained at minus 10° to 0° Fahrenheit. Cooking utensils, dishes and tableware shall be in good condition and proper cleaning facilities for this equipment shall be provided. dishes shall be stored in a clean, dry place protected from flies, dust or other contamination. Food preparation and serving areas shall comply with Section 19-13-B42 of the public health code. Proper food handling techniques and sanitation to minimize the possibility of the spread of food-borne diseases shall be maintained.
•	Two items in the freezer were not sealed properly.

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.

Keith Bryan______                                     6/30/23
Regulatory Consultant                                   Date

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

corrective_actions:
76. Kitchens, equipment, food
handling

description: 76. Kitchens, equipment, food