raw_content:
DCF Corrective Action Plan – The Bridge – Winifred STTAR Site

Corporate Name: The Bridge Family Center

Program Name: Winifred House STTAR                   Date: 10/7/24

The plan of correction should include specific goals, objectives, and steps that effectively resolve the issues described below. Please submit this plan to the undersigned by the close of business on 12/8/24. We hope to continue an ongoing dialogue with you as you work on this plan of correction. If you have any questions, please feel free to contact Kathleen Dituccio at kathleen.diticco@ct.gov

Area Needing Attention

The Bridge Plan of Correction

Completion Date

Title/Person Responsible to Monitor Plan

Section 17a-145-62. Chief administrative officer (Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.

a. Submit a comprehensive plan outlining how staff are trained/re-trained in all policies and practices related to medication administration, to include all processes, supervision of staff, documentation, and other quality assurance measures to ensure the effective execution of the agency’s medication administration program.

 b. Submit a detailed plan outlining how                                                                            the outside condition of the home will be addressed, repaired, and maintained on a consistent basis.

Physical plant: broken patio chairs, broken patio umbrella, deck floorboard, broken grill, graffiti on the siding of the house.

Section 17a-145-75. Health and medical treatment. Administration of first aid. Prescription medication. Administration of medicine or treatment. Written records. Storage of drugs, medicines, and instruments. Sick room, telephone.

Section 17a-6(g)-16(b) Facility is responsible for the provision of adequate back-up by licensed personnel to meet the needs of youth.

Submit a comprehensive plan outlining: 1. How drugs, medicines and medical instruments will be available to med certified staff for distribution to residents 2. How med certified staff will be trained & re-trained (also see above regulation Section 17a-145-62) 3. The oversight and supervision of med certified staff, 4. communication between staff and from staff to supervisors 5. Notification plan when med errors occur 6. Nursing responsibilities to ensure the effective oversight of the med admin program to include frequent education of med cert staff 7. Remedial consequences for staff that violate this plan.

Submit a plan that outlines DCF’s requirement that a larger percentage of staff are trained in the medication administration program to ensure staff coverage issues do not occur. This requirement will include supervisory and on call staff.

On 9/4/24 & 9/5/24, AF missed four days of medication due to refills not replenished.

Between 9/6/24 – 9/9/24 youth (AF) missed his medication due to a compromised lock box for controlled medication.?Also, on 9/8/24, there was no Med Certified staff to administer medications to two youth (AF, AG)

Staff failed to follow the agency's policy and procedures regarding notification in the event med certified staff is unavailable to administer medications. Staff also did not notify supervisors immediately regarding the compromised lock box.

On 9/25/24, DCF was notified that there was a medication administration error that occurred on 9/24/24, in which one youth (AG) was given two incorrect medications that were prescribed to youth (AF).?

On 9/24/24, agency staff failed to notify other staff or their supervisor of the medication error.

Section 17a-145-73 Sleeping Accommodations.

 Submit a detailed plan outlining how the conditions of the home will be addressed and maintained on a consistent basis.

Single bedroom- 1st floor bedroom-desk has graffiti/writing on it.  The curtains need to be replaced as they appear worn.

Double bedroom-2nd floor (right of bathroom)- bedroom was extremely unkempt with clothes, food/candy wrappers, broken fan, burn marks on desk chair, dirty bedsheets on one (1) bed, missing bedsheets and pillow protectors/pillowcases on two (2) beds.

Double bedroom-2nd floor (left of bathroom)-damaged walls (old repairs/patches to the wall need to be painted and a new hole in the walls needs to be repaired), missing electric switch plate cover, bedroom extremely unkempt with clothes, food/candy wrappers, burn marks on hardwood floor.

Section 17a-145-74 Lavatory facilities: Toilet articles and linens.

Submit a detailed plan outlining how the conditions of the home will be addressed and maintained on a consistent basis.

2nd floor bathroom- bathtub was extremely dirty, paper towels were missing, hand soap dispenser is broken and needs to be replaced, sink had hair and dried up toothpaste in it, the mirror was smeared with a white substance, and the electric outlet switch plate was missing.

Section 17a-145-76. Kitchens, equipment, food-handling.?

Submit a detailed plan outlining how                                                                            the conditions of the home will be addressed and maintained on a consistent basis.

There was unwrapped food in both the refrigerator and the freezer in the kitchen.?

Section 17a-145-77: Dining Areas and Supervision.?

Submit a detailed plan outlining how the conditions of the home will be addressed and maintained on a consistent basis.

The dining room table has only five chairs (5) and the program's licensed bed capacity is 6.?|


state: CT

facility_name: Bridge Family Center

summary: Visit covered 10 main areas/topics. Found 3 compliance issues.

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 / Winifred House/The Bridge Family Center

TIME OF VISIT (FROM TO): 10:15-11:15am			DATE: 7/24/24

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Director of Residential Services
		Program Manager
Director of Clinical Services
	     	Clinical Coordinator

List of Areas / Topics covered during visit:

•	Census = 6 male; LBC= 6
•	Status reports on residents
•	Staffing Updates: 2nd shift:  One(1) full time youth worker
•	Staff/client interactions:  three (3) youth were in bedroom, one (1) youth was AWOL, one (1) was at school.
•	Decrease in Risk Management reports
•	New agency vehicle
•	New furniture observed in dining and living room.
•	Landlord agreed to replace the stair railing on the 2nd floor.
•	New programming-Bridge Bucks to increase program compliance/participation.

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens

•	Bathroom door latch was broken-work order submitted.

Please submit a Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.

Amita Patel			Date:8/1/24
Regulatory Consultant

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

type: general

description: Bathroom door latch was broken

description: work order submitted.


summary: Visit covered 9 main areas/topics. Found 1 compliance issues.

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 / Winifred House/The Bridge Family Center

TIME OF VISIT (FROM TO): 2-4pm   			E  4/17/24

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Director of Residential Services
Director of Clinical Services
	     	Program Director

List of Areas / Topics covered during visit:

•	Census = 6 male; LBC= 6
•	Status reports on residents
•	Review of Pending Regulation Compliance Plans-combined response
•	Review of procedures for Staff office, agency vehicle and lock box keys
•	Staffing Updates: Clinician (newly hired), Vacancies; 4 part time direct care staff (weekends)
•	Staff/client interactions (4 youth home, 1 youth at school, 1 youth AWOL)
•	Risk Management
•	Dining Table & Living Room Couch ordered (delivery pending)

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63 Chief Administrative Officer:
•	2 Stair Railing Spindles Missing (indoors) work order placed
•	Outdoor Railing wobbly Side door (1st Floor) contractor quote requested

Section 17a-145-73-Sleeping Accommodations:

•	Single Bedroom-1st Floor Bedroom
o	Missing Window Screen (Work Order placed)

•	Single Bedroom (B)-2nd Floor Bedroom
o	Missing Window Screen (Work Order placed)
o	Hole Behind the Bedroom Door (Work Order placed)
o	Damaged Door Frame (Work Order placed)

•	Double Bedroom -2nd Floor on Right of bathroom
o	Missing Window Screen
o	Graffiti behind Bedroom Door & Front of Closet doors

•	Double Bedroom-2nd floor (Left of Bathroom)
o	Missing Curtains/blinds (Double Bedroom-2nd floor on Left of Bathroom)
o	Missing Window Screen
o	Excessive Dirty Clothes piled up, unpleasant odor
o	Food on the floor (orange peel)

Section 17a-145-76: Kitchens, equipment, food-handling:

•	Oven-inside needs to be cleaned

Section 17a-145-84: Office Space. Confidential Files
•	Closed records are stored in the staff office in boxes (Locking Filing Cabinet Ordered)

Please submit a Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.

Amita Patel			Date:4/18/24
Regulatory Consultant

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


summary: Visit conducted on 1/19/24. Visit covered 7 main areas/topics. Found 1 compliance issues.

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 / Winifred House/The Bridge Family Center

TIME OF VISIT (FROM - TO):     9am to 12pm				DATE:  1/19/24

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  Director of Residential Services
	       Clinical Director of Residential Services

List of Areas / Topics covered during visit:

•	Census = 6 male; LBC= 6
•	Status reports on residents
•	Review of significant events
•	Staff office keys obtained by youth leading to access to staff office, lock box and agency vehicle keys
•	Agency vehicle stolen by two (2) youth on 1/18/24
•	Contraband (BB gun) located in bedroom on 2nd floor
•	Camera footage observed (1/18/24)

Milieu observation:
•	Staff/client interactions (3 youth home, 1 youth at school, 2 youth detained by police)

Physical Plant observed to be improved to prior visits

Areas of regulatory non-compliance identified during this visit:

•	Section 17a-145-61: Written Policies & Procedures:
- The program failed to adhere to room search policy and confiscate contraband (BB gun)

•	Section 17a-145-63:  Chief Administrative Officer:

- The program failed to properly ensure the safety of residents.  There was a BB gun in the program on at least two (2) reported occasions.  Management failed to properly report, secure, and dispose of the BB gun.

Program staff failed to ensure safety of the residents. Two residents gained access to staff office keys, which also granted them access to the lock box, within the office, with sharps, vehicle keys and petty cash.  Safety measure/protocols need to be updated to prevent this from future occurrence.

•	Section 17a-145-73:  Sleeping Accommodations:

- Two (2) damaged doors (office door, 2nd floor bathroom door)
- 1st floor bedroom has two (2) broken windows that were boarded up

Please submit a Regulation Compliance Plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.

Amita Patel			Date:4/5/24
Regulatory Consultant

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

description: There was a


summary: Visit covered 6 main areas/topics. Found 4 compliance issues.

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:  Winifred House/ Bridge Family Center

TIME OF VISIT (11am to 1:15pm):     				 				DATE:9/8/23

 AGENCY PERSONNEL WHO PARTICIPATED:
Clinical Coordinator
Intern

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Client Supervision- Frequency & Documentation
•	Status reports on residents
•	Client vocational and education placements
•	Discharge planning

Milieu observation:
•	Staff/client interactions (4 youth home, 1 youth in school and 1 youth AWOL)

Physical Plant tour:

•	Broken Furniture (Bedroom B, Dining Room Chair)
•	Floor Damage/Stains (Bedroom B)
•	Broken Radiator Cover near Laundry Machines
•	Vape Cartridge found under mattress and confiscated  (Bedroom B)
•	Food observed in Bedroom B
•	Large Garbage Bag full of trash including pizza box (Bedroom B)
•	Clothes strewn all over floor in bedrooms
•	Bathroom -1 bulb needs to be replaced, no paper towels or Hand Soap
•	Basement-evidence of fly infestation (around door frame), debris from construction needs to be cleaned
•	Chipping Paint throughout the home
•	Walls need to be cleaned/repaired/re-painted - throughout the home.
•	Doors need repair due to dents/cleaning and/or to be painted - throughout the home.
•	Microwave-inside needs to be cleaned.

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73: Sleeping Accommodations
•	Bedroom on first floor:
1. Two youth are sharing a bedroom and the room is not large enough.

•	Bedrooms on second floor:
1.	Bowl with old food found in bedroom (Bedroom B)
2.	Vape Cartridge found under mattress and confiscated (Bedroom B)
3.	Large full bag of trash including pizza box (Bedroom B)
4.	Clothes strewn all over floor in bedrooms located on 2nd floor.

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens
•	Bathroom -1 bulb needs to be replaced, no paper towels or Hand Soap, Several Bars of soap stuck together and used washcloths observed in shower
•	Bathroom on first floor- toilet bowl dirty, towels on the floor, no hand soap

Section 17a-145-76: Kitchens, equipment, food-handling:
•	The hood/Vent above the stove is missing filter grids.
•	Microwave-inside needs to be cleaned.

Section 17a-145-77: Dining areas and supervision:
•	The dining room chair is broken.  Not enough chairs at the dining room table for all the youth to sit.

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.

Amita Patel			Date:     9/14/23
Regulatory Consultant

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

area_type: Bedrooms on second floor

description: Bowl with old food found in bedroom (

facility_name: Winifred House/ Bridge Family Center


summary: Visit conducted on 8/16/23. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Bridge Family Center / Winifred STAR

 TIME OF VISIT (FROM - TO):     11am-2pm               DATE: 8/16/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	SIU Investigator
	Clinical Coordinator
	Hartford PD Detective

List of Areas / Topics covered during visit:
•	LBC 6.  Census is 6.
•	This is an unannounced visit to assist SIU Investigator & Hartford Detective follow up on a Careline report, 7/23/23.
•	At the time of the visit 5 youth were home.
•	Discussed programing as it relates to resident behavior and the challenges working with youth in a STAR environment.  At the time of the visit residents appeared calm, but there is an undercurrent of negativity by one youth that has a ripple effect in the milieu. Staff make attempts to address their concerns, by speaking to residents directly and separate youth when needed.
•	Given the nature of the youth trauma history; staff's training was discussed and as well as how will the program maintain safety in the milieu.
•	Discussed the challenges of discharging unsafe residents and its effect on the milieu and staff when a resident is unable to leave.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
 No SDP

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

Thomas S. Cuchara                           2/8/24
Regulatory Consultant                         Date

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

description: No SDP

facility_name: Bridge Family Center / Winifred STAR


summary: Visit conducted on 4/19/23. Visit covered 4 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Bridge Family Center / Winifred STAR

 TIME OF VISIT (FROM - TO):     11am-1pm               DATE: 4/19/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Clinical Coordinator

List of Areas / Topics covered during visit:
•	LBC 6.  Census is 5.
•	At the time of the visit one youth home.  Youth stated he likes the staff.
•	Discussed the programing and resident behaviors.
•	Physical plant inspection completed.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-73. Sleeping accommodations.  Completed.
Evidence:
•	At the time of the licensing visit, the bedroom door to Room C was found broken.  A work order was submitted prior to the licensing visit.

Section 17a-145-74.  Lavatory facility.  Completed.
Evidence:
•	The second-floor bathroom sink was found to be broken at the time of the licensing visit.  A work order was submitted prior to the licensing visit.

Section 17a-145-84. Office space. Confidential files. Completed.
Evidence:
•	Closed records were found to be on the floor in the Program Director's office.  There is no evidence of a locked room or file cabinet dedicated to storage of closed files.

Section 17a-145-86.  Instructions in safety procedures. Completed.
Evidence:
•	Fire drill missing for the 4th quarter 2022.
•	Fire Marshal report: Basement area needs exit signs for occupants.  Completed.

Section 17a-145-84. Office space. Confidential files. Completed.
Evidence:
•	Closed records were found to be on the floor in the Program Director's office.  There is no evidence of a locked room or file cabinet dedicated to storage of closed files.

Section 17a-145-86.  Instructions in safety procedures.  Completed.
Evidence:
•	Fire drill missing for the 4th quarter 2022.
•	Fire Marshal report: Basement area needs exit signs for occupants.

Areas of regulatory non-compliance identified during this visit: NONE.
Section 17a-145-73. Sleeping accommodations.
Evidence:  At the time of the visit, a mirror was found to have inappropriate graffiti/statements written on the frame.  It was immediately removed by the Program Director.   No SDP.

Section 17a-145-76. Kitchen, equipment, food-handling.
Evidence:
•	At the time of the visit the cabinet door to the center island was missing.  A work order had been submitted prior to the licensing visit.  Repeat from last relicense inspection.

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

Thomas S. Cuchara                           4/19/23
Regulatory Consultant                         Date

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

personnel:
Program Director
Clinical Coordinator


summary: Visit conducted on ___11/16/22____. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _Bridge Family Center / Winifred

 TIME OF VISIT (FROM - TO):       1pm__________________               DATE: ___11/16/22____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
SB	Program Manager

List of Areas / Topics covered during visit:
•	Census is 5.  LBC 6.
•	4 youth were home at the time of the visit. Youth interacted positively with staff.
•	Physical plant inspection of the Group Home.  See below.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts. 1st and 3rd shifts have no vacancy.  Program is in process of reviewing resumes for one open 2nd shift position.
•	SB is new to agency, since 10/31/22.

Corrective Actions implemented as a result of previous visit:
 No SDM from last visit

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations.
Room C: The door frame and door were found broken at the time of the visit.  Repair or replace.

Section 17a-145-76. Kitchens, equipment, food-handling.
The kitchen has an island in the center of the room with cabinet space.  One of the cabinet doors is missing and should be replaced.

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

Thomas S. Cuchara                                 11/17/2022
Regulatory Consultant                                   Date

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

facility_name: _Bridge Family Center / Winifred


summary: Visit conducted on ___9/28/22____. Visit covered 4 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _Bridge Family Center / Winifred

 TIME OF VISIT (FROM - TO):       ___12:30pm__________________               DATE: ___9/28/22____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
AB	Youth Worker
HB	Youth Worker

List of Areas / Topics covered during visit:
•	Census is 3.  LBC 6.
•	Physical plant inspection of the Group Home.  See below.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Reviewed 1 open client file. Found to be in compliance.

Corrective Actions implemented as a result of previous visit:
 No SDM from last visit

Areas of regulatory non-compliance identified during this visit:
No SDM required.

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

Thomas S. Cuchara                                 11/10/2022
Regulatory Consultant                                   Date

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

description: No SDM required.

personnel:
AB	Youth Worker
HB	Youth Worker


facility_name: Bridge Family Center, Inc /WH STAR/ Freymann House

raw_content:
April 9, 2026

Ms. Margaret A. Hann
Executive Director
The Bridge Family Center, Inc.
1022 Farmington Ave.
West Hartford, CT 06107

Re: Freymann House STTAR Relicensing Inspection 2026
Licensing Consultants: Kathleen Forsythe, Amita Patel, Lori Read
DCF Nurse Consultant: Errolee Miller

Dear Ms. Hann,

On April 1-2, 2026, a biennial re-licensing inspection was conducted for the Freymann House temporary shelter STTAR program, located at 1019 Farmington Ave., West Hartford, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Child Caring Regulations 17a-145-48 through 17a-145-124, and the Health Care Standards for Children and Youth in Care.

Listed below are the areas of DCF regulatory non-compliance which were identified during the relicensing inspection. Please review the areas identified and complete a Regulation Compliance Plan (RCP) to address each area of noncompliance. The completed RCP must be submitted to the assigned Regulatory Consultant within 30 days of receipt of this emailed report.

The areas of regulatory noncompliance are as follows:

17a-6(g)-16. Utilization of Trained Persons to Administer Medication.
•	Evidence of quarterly training for DCF Medication Administration certified staff was not found.

17a-145-64	    Personnel Policies and Procedures.
17a-131	         Cardiopulmonary resuscitation training for people who directly supervise children.
46a-154         	Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
17a-101	         Protection of children from abuse. Mandated reporters. Education and training programs. Model mandated reporter policy.
29-17a	          Criminal history records checks. Procedure. Fees.
•	The personnel file of one employee (RM) did not contain evidence of CPR certification, physical intervention training (TCI), and mandated reported training in compliance with agency policies in these areas.
•	The personnel file of one employee (RM) did not contain evidence of a national criminal history check through the FBI completed by the Connecticut State Police Bureau of Identification.

17a-145-73     	Sleeping Accommodations.
•	The walls of the six bedrooms in the house contain numerous areas of chipped/missing paint.

17a-145-74     	Lavatory Facilities. Toilet Articles and Linens.
•	The sink in the third-floor bathroom is stained and missing the drain stop; drain stop is missing in the sink in the second-floor bathroom.

17a-145-93     	Medical, dental and nursing care.
•	Comprehensive Nursing care plans were not found in the four active medical records reviewed.
•	Two of the four records reviewed had an initiated Nursing care plan that was written following the admission process, however no follow up focused individual plan of care, intervention or evaluation of problem or problems identified were documented on the care plans.
•	Nursing signatures without date and time were observed on April 2026 MAR's.

17a-145-98     	Case Records. Reports. Confidentiality.
Four open and three closed case records were reviewed. The following deficiencies were noted:
•	Health history information was not included on intake assessments in three case records (ZJ, SR, LS).

****************************************************************************************************
Once the Licensing Unit has reviewed and accepted the completed Licensing Regulation Compliance Plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe, LCSW
Regulatory Consultant
Dept. of Children and Families

cc: File
     Director of Residential Services
     Program Director|

report_type: unstructured


summary: Visit conducted on 1-22-26. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):     10:45a-12:30pm         		DATE:  1-22-26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Director

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

A meeting was held with the Program Director. Topics discussed included:
•	Census: 4 females.
•	Staff vacancies: one anticipated full time second shift slot; 2 part-time biweekly weekend slots; shift supervisor position.
•	Planned maintenance projects for the next few months: interior painting, rear deck replacement, relocating medication room, renovation of three bathrooms.
•	Case records: format review; planned transition to an electronic case record in the spring.
•	Allowing staff access to client treatment plans.
•	Current residents: education plans, reduction in AWOL incidents, supervision.
•	Upcoming biennial relicensing inspection scheduled for April, application materials.
•	Bedroom furniture to be replaced.
•	Snow removal by contractors.

Milieu observation:
•	One client observed taking out trash & departing for the store with staff; one client prepping to attend off-site school program in the afternoon; one staff positioned in living room.

Physical Plant: Program Director facilitated tour of physical plant.

Corrective Actions implemented as a result of previous visit: A regulation compliance plan (RCP) was submitted by the program last month and accepted by the Department.

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

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

Kathleen Forsythe, LCSW				                     Date:  1-22-26
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
Cc: 	Director of Residential Services, Program Director, File|


summary: Visit conducted on 11-17-25. Visit covered 1 main areas/topics. Found 2 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO): 10:30am-11:45am		        DATE:  11-17-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	HR Director

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review for recently hired staff. Four personnel files were reviewed. See 'Area of regulatory Non-compliance'.

Corrective Actions implemented as a result of previous visit: A Regulation Compliance plan following an October 2025 visit to Freymann House was received on 11-12-25 and accepted by the Department.

Areas of regulatory non-compliance identified during this visit:

17a-131. Cardiopulmonary resuscitation training required for persons who directly supervise children.
-Evidence of CPR certification is missing in one personnel file for an employee hired four months ago.

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

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

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

Cc: 	Director of Residential Services
       File|


summary: Visit conducted on 10-21-25. Found 8 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):     11:00am - 1:30pm		           DATE:  10-21-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Director
•	Clinical Coordinator
•	Facilities Director

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

A meeting was held with the Program Director and Clinical Coordinator. Topics discussed included:
•	Census: 4 females; referrals.
•	Discharge plans for current residents.
•	Incidents: AWOL's; data for the quarter; hospital visits; EC submission by on-call staff; clarifying 'smoking' on EC's.
•	School attendance: All current residents have a plan for education; frequent refusals to attend; medication refusal.
•	Staff vacancies: One full-time first shift slot and three part-time biweekly weekend slots; second shift supervisor returned from maternity leave.
•	New Clinical Coordinator began employment last month; overlap with outgoing Clinician.
•	Upcoming Halloween party invite to another Bridge STTAR program.
•	DCF funding for security enhancements.
•	Proposed fencing for front yard.
•	Phones: New desk phones and one cordless phone installed; no plan for phone in third floor bedroom area; proposed cell phone for staff use in community.
•	New laptops secured for on-call staff to submit timely EC's to the Department.
•	Licensing to conduct semi-annual personnel file review next month.
•	Case record documentation: Family engagement documentation section added; processing notes by direct care staff for use in treatment planning, STTAR reviews, etc.
•	Case record storage: Discussed need to ensure case record storage area is locked; plan to move storage cabinet to first floor closet.

Milieu observation:
•	Three electricians and Facilities Director on site; installation of exterior camera, lighting and alarms.
•	One client in bed, one in shower on third floor, one awake and in her room.
•	Two female staff seated in living room; discussed staff stations for client supervision with Program Director.
•	Brief interview with one client re: school attendance.

Physical Plant: Program Director and Clinical Coordinator facilitated tour of physical plant. See 'Areas of Regulatory Non-compliance' below.
•	All areas appear clean and organized, including bedrooms.
•	Lower wall of storage nook in front stairwell has been painted.
•	New medication room on first floor not in use. Facilities Director reported that security enhancements to be installed by 10/31/25; Dutch-style door has been installed; discussed need for electrical outlet for medication refrigerator, table lamp, etc. as well as need for room to have light switch inside of room rather than outside.
•	Discussed plan to transition the first-floor classroom to a 'girl cave' for recreation/leisure activities.
•	Estimate reportedly secured to repair and replace weak area on living room floor.
•	Carpeting in interior stairwells to be replaced with laminate.
•	Two vacant bedrooms; room #6 being used as temporary storage.
•	Discussed staff refrigerator and toaster oven.

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

Areas of regulatory non-compliance identified during this visit:

17a-145-71	Living room, lounge.
•	Livingroom floor vents contain rust.

17a-145-73	Sleeping accommodations.
•	All bedroom walls contain areas of peeling/chipped paint and scuff marks.
•	Bedroom #3 contains a dent in a wall.
•	Bedroom #4 contains peeling/chipping on the ceiling.

17a-145-74	Lavatory facilities. Toilet articles and linens.
•	First floor bathroom walls contain scuff marks and are need of repainting; rust is visible on heating elements.
•	Heating element in staff bathroom contains rust.

17a-145-76	Kitchen, equipment, food handling.
•	A/C wall unit in kitchen contains dust and rust.

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

Kathleen Forsythe, LCSW                          				Date:  10-24-25
Regulatory Consultant

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

Cc: 	Director of Residential Services
       Program Director
       File|

description: 71 Living room, lounge.

description: Bedroom #3 contains a dent in a wall.


summary: Visit conducted on 7-9-25. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):     10:00am-1:00pm		          DATE:  7-9-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Director
•	Director of Residential Services

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

A meeting was held with the Program Director and Director of Residential Services. Topics discussed included:
•	Census: 5 females; one client currently hospitalized; one client on home visit; one client assigned 1:1 staffing on second shift until 7-20-25.
•	Discharge plans for current residents.
•	AWOL's.
•	Training on trafficking with task force to be conducted this summer; one Bridge staff member is a trainer on trafficking.
•	Follow-up conducted by Program Director with staff re: call to the Careline last month.
•	July staff meeting topics.
•	Staffing vacancies: 3 part-time biweekly weekend slot staff vacancies; one full time new hire in the on-boarding process; shift supervisor on maternity leave, weekly on-call direct care staff assignment, use of a temp agency staff for one shift this weekend.
•	Bridge Residential Care policy manual: Management is overhauling residential care policies; will provide to DCF Licensing this summer.
•	Medication certified staff: Currently six staff are certified, two staff currently taking the course.
•	Rec & Leisure: Book Club Mondays, 4th of July, Lake Compounce, morning and evening rec activities each day; weekend re-cap meetings; unescorted walks in community currently on pause.
•	Client treatment plans: Staff still do not have immediate access; Director of Residential Services to ensure treatment plans are immediately available to staff effective today; recommendation to involve direct care staff in the treatment planning process; behavior plans.
•	The Bridge Family Centers received accreditation by COA for the next three years.
•	Training: New employee orientation process; new training videos under development; quarterly clinical training for direct care staff; med cert staff quarterly training; weekly Director's meetings for Bridge STTAR programs.
•	Bridge administration requests current LBC remain the same.
•	Standardization of practices in Bridge STTAR homes complete.

Milieu observation:
•	Clients observed at kitchen table having lunch and completing a word-search contest; intern observed in staff office, Clinical Coordinator in session with client.

Physical Plant: Directors facilitated tour of physical plant.
•	All areas appear generally clean and organized.
•	Donation of clothing items observed in game room.
•	Livingroom contains four couches that have been repurposed from another Bridge program.
•	Walls, doors and baseboards in all bedrooms, bathrooms and common areas are in need of painting and/or cleaning.
•	Maintenance worker is following up with a floor installer re: weak area on living room floor.
•	One Maintenance worker for all Bridge residential homes; reportedly visits Freymann House "at least weekly".
•	Large closet in game room to be converted to medication room this summer w/ Dutch-style door installed; consult with Fire Marshal determined current med room location cannot have a Dutch-style door installed; recommendation to follow up with Fire Marshal re: enclosing the top of the proposed new location for med room which is open near the ceiling.
•	Window screens/guards were observed in game room waiting to be installed on this date.
•	Several holes observed on walls in bedroom # 2 noted in previous Licensing visit remain unrepaired.
•	A/C unit in kitchen and floor vent grates in living room contain large amount of rust.
•	Food storage room: Room is quite warm; recommendation made to install air conditioner to prevent food spoilage.
•	Director reported unused items in basement to be removed this summer.

Corrective Actions implemented as a result of previous visit: A regulation compliance plan (RCP) was submitted by the program and accepted by the Department last month regarding bedroom window screens.

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

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

Kathleen Forsythe, LCSW				                 Date:  7-10-25
Regulatory Consultant

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

Cc: 	Director of Residential Services
      Program Director
      File|


summary: Visit conducted on 6-12-25. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):     1:45pm-4:00pm		             DATE:  6-12-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Director
•	Shift Supervisor
•	Clients

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

A meeting was held with the Program Director. Topics discussed included:
•	Census: 5 females.
•	Staffing: 1 full-time third shift slot, 3 part-time biweekly weekend slot staff vacancies - numerous hiring interviews conducted; upcoming maternity leave (8 weeks) for second shift supervisor; interim assignment of duties to a lead staff; onboarding of new staff.
•	Restorative Justice (RJ) model: Four direct care staff, Program Director, Clinical Coordinator and shift supervisor trained in RJ practices. First meeting held with RJ consultant in April 2025, second consultation meeting scheduled for this week. Program Director to inquire about RJ 'train-the-trainer' opportunities for The Bridge.
•	Program Director to follow up on child caring license revision to reflect lower bed capacity.
•	AWOL's; Two clients admitted in May 2025; data for past twelve months reflects a significant reduction.
•	Possible peer mentor initiative.
•	Meeting schedule with IT next week to discuss program's ability to submit exceptional circumstance forms to DCF on weekends/after hours.
•	New season passes for Lake Compounce.
•	Menu development with client input.
•	Summer schedule for clients: life skill training on first shift, two clients participating in credit recovery, rec activities.
•	Treatment plans not available to staff; treatment plan goals, therapeutic walk and AWOL response plans discussed in staff meetings and daily as needed.
•	Communication practices with staff.
•	Operational definitions: discussed identifying terminology used by The Bridge and formally defining terms in a written policy.
•	Policy manual for Bridge Family Center child caring facilities: Program Director to follow up and provide final version.
•	Standardization of practices in Bridge STTAR homes.
•	Sections of Residential Staff Handbook reviewed in monthly staff meetings.

Milieu observation:
•	One client in a private meeting with DCF staff and lawyer.
•	Clients observed dancing in living room with staff, making a snack.
•	Staff shift change: three direct care workers and a shift supervisor reporting for second shift.
•	Brief interviews with two clients.

Physical Plant: Program Director facilitated tour of physical plant.
•	All areas appeared organized and generally clean.
•	Second floor bathroom light has been replaced; new bathroom light ordered for first floor bathroom.
•	Dutch-style door for Medication room: replacement door ordered two weeks ago.
•	Old freezer chest has been removed from the med room/storage room.
•	Temperature quite warm on second floor; air conditioning units in five bedrooms, A/C installation in bedroom #2 scheduled for tomorrow.
•	New patio furniture on deck.
•	New communication white board in staff office.
•	Bedrooms and bathrooms in need of painting to address degraded surfaces.
•	Utility area in front stairwell has been recently painted.

Corrective Actions implemented as a result of previous visit: A regulation compliance plan (RCP) was submitted by the program and accepted by the Department regarding regulatory deficiencies noted during a personnel file review. A second RCP is pending submission regarding bedroom window screens.

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

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

Kathleen Forsythe, LCSW				                    Date:  6-13-25
Regulatory Consultant

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

Cc: 	Director of Residential Services
      Program Director
      File|


summary: Visit conducted on 5-19-25. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):     12:30pm-3:00pm        		DATE:  5-19-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Clinician

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

A meeting was held with the Program Manager and Clinician. Topics discussed included:
•	Census: 5, including one client in the hospital and one client in detention; one current vacancy; K. slated for discharge on 5/21/25.
•	Staff vacancies: four part-time (16 hr) slots; new program nurse hired in March 2025.
•	Incidents: Recent AWOL's and police involvement.
•	Circumstances leading to increase in incidents (upcoming discharge, one client in program for 423 days, new client).
•	CFT individual meetings held with clients J. and K. last week; DCF workers did not attend; clients disappointed re: discharge plans; Program Manager and Clinician trained in CFT meeting facilitation.
•	DCF workers monthly visits with assigned clients: not all tour bedrooms, one worker visits weekly.
•	Three clients receive homebound tutoring.
•	Restorative Justice (RJ) behavior system going well.
•	Virtual meeting held with Program Manager and assigned RJ Consultant on 4-28-25; RJ Consultant to participate in virtual direct care staff training in June.
•	Game room
•	Treatment planning: monthly review meetings, staff do not have access to treatment plans - to be corrected this date; data collection, developing measurable goals and objectives; operational definitions, all treatment plans in process of revision to be completed next week with staff training scheduled.
•	Quarterly clinical training for direct care staff.
•	Recreation: Two residents currently participating in a flag football league; three clients attending church with staff supervision; increase in board game activities; plantings at house exterior.
•	Performance improvement opportunities: measuring effectiveness of new program initiatives, involving staff in developing training topics.
•	Council on Accreditation (COA) survey held in late April 2025 for The Bridge Family Centers; surveyor only toured Freymann House for the residential portion of survey; positive feedback received from surveyor.

Physical Plant: Program Manger facilitated tour of physical plant. See 'Areas of Regulatory Noncompliance' below.
•	All areas appeared organized and generally clean.
•	New room-darkening curtains in bedrooms.
•	Carpeting replaced with new vinyl flooring in bedrooms.
•	Outside pane of double pane window broken on main floor; glass company on site last week & ordered replacement.
•	Leftover lunch food items observed inside oven - food safety discussed.
•	Second floor bathroom walls in need of painting; vanity light is missing two bulbs.
•	Bedrooms appeared organized with exception of bedroom #3 (client in hospital).
•	Cabinet/drawer pulls missing on a kitchen cabinet and some bedroom dressers.
•	Several holes observed in walls in bedroom #2 - work order has been submitted.
•	Dutch-style door for Medication room: approved by administration; work order has been submitted.
•	Baseboards and windowsills are in need of cleaning throughout the house.
•	Standing freezer and freezer chest in Medication room are in need of defrosting.
•	Window screens missing from numerous open windows.

During the past quarter, the Licensing Unit responded on 5-5-25 to one incident and completed an Incident Response Note. The incident occurred in March 2025 and involved an unsubstantiated allegation of medical neglect.

Follow-up telephone call held with Program Manager on 5-20-25; topics discussed included:
•	Client/peer boundaries: written guidelines included in Residential Handbook; clients and residents receive training at admission/hire; workers and direct care staff informed of developing romantic relationships; enhanced supervision for identified clients.
•	Update on police investigation from earlier this month re: video recording distribution; charges pressed on one client; clients involved have been discharged.
•	Wish list items from DCF re: client safety.
•	DCF workers invited to attend monthly treatment planning meetings and do not attend. DCF workers do attend bi-weekly STTAR meetings where treatment plans are discussed.
•	Client D.: has been in program for well over one year; inconsistent/lack of communication from worker; school laptop computer delivery has been delayed since February due to funding delay from Department; no discharge plan.
•	Supervision levels for clients; how information is communicated to staff.

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

Areas of regulatory non-compliance identified during this visit:
         17a-145-73	           Sleeping Accommodations.
1.	Window screens are missing from open windows in Medication room and bedrooms #2, #3, #4, #5.
2.	Bird guard plate for portable air conditioner vent is missing from window in bedroom number #4.

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

Kathleen Forsythe, LCSW                  				Date:  5-20-25
Regulatory Consultant

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

Cc: 	Director of Residential Services
      Program Manager
      File|

personnel:
•	Program Manager
•	Clinician


summary: Visit conducted on 5-6-25. Visit covered 2 main areas/topics. Found 3 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):      9:00am- 11:00am          	DATE:  5-6-25

AGENCY PERSONNEL WHO PARTICIPATED:
    Job Titles:
•	HR Director

List of Areas / Topics covered during visit:  This was a scheduled visit to the Human Resources office to conduct a semiannual personnel file review. Two files were reviewed.  See Areas of Regulatory Non-compliance below.

•	The personnel file of the program nurse (JE) does not contain evidence of CPR certification.

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

Areas of regulatory non-compliance identified during this visit:
17a-145-64	Personnel Policies and Procedures.
•	Results of TB testing were not obtained immediately prior to hire in two files. JE's results are dated approximately four months prior to assuming duties and JM's results are dated approximately six months prior to assuming duties.

17a-151    Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	The results of a national criminal history background check are missing in two files (JE, JM.)

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

Kathleen Forsythe, LCSW				                           Date:  5-6-25
Regulatory Consultant

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

Cc: 	HR Director
       File|

description: 64 Personnel Policies and Procedures.


summary: Visit conducted on 3-6-25. No compliance issues identified.

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

                                            Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):      10:00am-1:20pm               	DATE:  3-6-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Director of Residential Services
•	Clinician
•	Youth worker
•	Clients

List of Areas / Topics covered during visit:  This was a scheduled visit following an unannounced visit in January 2025.

A meeting was held with the Program Manager, Clinician and the Director of Residential Services. Topics discussed included the following:
•	Census: 6 female residents, including one hospitalized client; meeting scheduled tomorrow at the hospital.
•	Staffing:
o	Vacancies include 1 full time first shift, 3 part time second/shift weekend and 1 full time third shift.
o	Applicant accepted the nurse position on this date, with start date of 3-24-25.
•	Staff training:
o	2024 focused on training for engagement with clients.
o	2025 focus on maintenance of program schedule, increased oversight and accountability with clients.
o	2025 quarterly training on clinical topics for direct care staff.
o	Virtual meeting with Dojo Class rep held yesterday.
•	Program Manager certified as TCI instructor.
•	House keys; ensuring direct care staff have access at all times.
•	Treatment planning: process, frequency of review, client and DCF worker involvement, signatures; housekeeping added to plans for identified clients, staff access to treatment plans.
•	School attendance:
o	Two clients attending school in community,
o	Three clients receiving tutoring,
o	One client pending school assignment; structured daytime schedule for clients who refuse school attendance.
o	School participation has improved in recent months.
•	Culture shift:
o	Effective 3-3-25 new positive praise cards issued randomly to staff, exchange for prizes.
•	New Restorative Justice (RJ) behavior management system effective 2-1-25:
o	Level system with privileges.
o	Levels reviewed every 3-4 weeks.
o	Daily data collection, operational definitions for identified categories.
o	'Amplify RJ' focus, helping staff understand why clients display certain behaviors.
o	'Class Dojo': customizable phone app for clients to track areas of positivity and areas needing improvement; 90-day pilot program at Freymann House started 2-14-25.
o	Performance improvement opportunities for the program.

•	Case records: Organization of case record material overhauled into organized 3-binder system (operations, clinical, medical).
•	Significant events and property damage have decreased in past few months.
•	Incident response note: Incident earlier this week re: client with a knife.

Milieu Observation: One staff observed cooking dinner; one staff prepping to take two clients for a community ride; staff reported increase in client participation at group mealtimes.

Physical Plant:  Staff facilitated a tour of the 1st, 2nd, and 3rd floors.
•	All common areas appeared clean and organized.
•	New indoor basketball hoop and video game system.
•	Entry and stairwell carpets are in need of vacuuming.
•	Bedrooms:
o	One bedroom contained unmade bed and clothing on floor; addressed on client's treatment plan.
o	Five bedrooms are organized with beds made.
o	Bedrooms walls contain chipped walls and are in need of repainting. Broken mini blinds on some bedroom windows.
o	One bedroom contained strong smell of marijuana; Manager reports the smell clings to client's stored clothes.
o	Carpeting in all bedrooms has worn appearance and contain stains; flooring slated for replacement this year.
o	Plastic mattress protector covering missing on several beds.
•	No telephone observed on third floor. Manager reported that house will be receiving new phones and computers.
•	Dirty walls observed in first floor bathroom; client bathroom sinks contain stains.
•	Dining table contains only three chairs. Manager reported additional chairs can be found in lower-level game room; new dining chair delivery arrived in the afternoon.
•	Front stairwell windows contain new privacy film; ceiling light cover missing.
•	Interior painting scheduled for this year.
•	Metal hardware on sectional couch pieces to be removed.
•	Furniture placed over damaged section of living room floor.

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

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

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

Kathleen Forsythe, LCSW				Date:  3-7-25
Regulatory Consultant

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


summary: Visit conducted on 1-30-25. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):      1:10pm-3:00pm	           DATE:  1-30-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Youth Workers
•	Clients

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

Census: 6 female residents.

Milieu Observation:
•	Upon arrival to the house one staff person was present with 4 clients.
•	A second staff person was reported to be off-site retrieving house keys from another staff person who inadvertently took them home; Second staff person on-duty returned to the group home within approximately 20 minutes of start of Licensing visit.
•	One client was observed in the living room watching television, two clients were socializing in a third-floor bedroom, one client was observed returning to the house by a state worker (from a court appearance), two clients were reported to be on a walk in the community.
•	Staff reported that Program Director and Clinician were off site at a meeting.
•	Maintenance staff arrived to repair holes in client bedroom wall.
•	Staff observed later assisting a client with hair care.

Staff interviews: Staff reported on the following:
•	Use of 15-minute headcount sheet documentation.
•	Weekly/monthly menu and recreation schedule reviewed.
•	Staff described use of Restorative Justice model practices.
•	Client chore list.
•	Behavior management/reward level system.
•	Client allowance practices.
•	Recent recreation activities.
•	No DCF medication certified staff on duty - shift assignment sheet indicates clinician is the designated person on-call and could be contacted to give prn medication if needed.
•	School attendance refusal by several clients.
•	Caseload assigning on each shift.
•	Two clients on a walk in the community did not return during allotted time and would be reported as AWOL.

Client interviews: Brief interviews with three clients. Clients reported on:
•	Satisfaction with the program and staff.
•	Level system and weekly allowance money.
•	Reasons for not attending school during this Licensing visits.
•	Meal preparation and client involvement.
•	Client rewards.
•	Dying their hair.

Physical Plant:  Staff facilitated a tour of the 1st, 2nd, and 3rd floors.
•	All common areas appeared generally clean and organized.
•	Entry and stairwell carpets are in need of vacuuming.
•	Five of 6 bedrooms appeared very messy, contained unmade beds and large amounts of clothing and personal items on the floors. No sheets observed on bed in room # 3, but were present in the room.
•	Sitting food observed in two bedrooms.
•	Freezer chest in second floor storage room is in need of defrosting.
•	No telephone observed on third floor.
•	Loose or missing drawer pulls observed on dressers in bedrooms.
•	Two bedrooms on third floor contain large areas of patched repairs on walls.
•	Numerous articles of clothing and objects hanging on fire sprinkler pipes in room #3 - removed by staff during tour.
•	Two containers of cleaning supplies observed under sink in 3rd floor bathroom - staff removed during tour.
•	Floor vent covers (6) in living room are heavily rusted.
•	Floor under window is living room is buckled, possible from water damage.

Program Update: Program Director telephoned this Regulatory Consultant on 2-3-25 to provide a program update. Topics discussed included:
•	Medication certified staff: 5 Youth Workers, Program Director and Clinician are currently certified to pass medication; one staff's certification is pending, and one staff is newly enrolled in the training course.
•	House repairs: The Bridge Family Centers has one Maintenance worker for seven buildings. Turn around time for repairs varies but occur in approximately one week.
•	Restorative Justice training: Five staff have completed the course; more will be enrolled when training is next offered.
•	New game room; new level system.
•	Headcount sheets.
•	Notification procedures when a staff member leaves the house during shifts.
•	Status of current residents.
•	Bedroom window coverings: One client's insistence on using a personal blanket over window rather than the window shade.
•	Anticipated accreditation survey (COA) scheduled for April 2025.
•	Incident data from past three months:
o	AWOLS (25 in November, 5 in December, 4 in January). All incidents reported to police.
o	Hospital visits: one in December, 1 in January, both for psych evaluations.
o	Police response to house for disturbance: 1 in December.

Corrective Actions implemented as a result of previous visit: A Regulation Compliance Plan was submitted to the Licensing Unit by the program following an October 2024 Licensing visit. The RCP was accepted by the Department.

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

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

Kathleen Forsythe, LCSW				                          Date: 2-3-25
Regulatory Consultant

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

Cc: 	Residential Director
      Program Manager
      File|

personnel:
•	Youth Workers
•	Clients


summary: Visit conducted on 11-6-24. Visit covered 1 main areas/topics.

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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):      9:00am-10:30am		DATE:  11-6-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	HR Director

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to the Bridge Family Centers Human Resources Dept. to conduct a semiannual personnel file review for new hires, interns, etc. that are assigned to Freymann House.

•	Four (4) personnel files were reviewed. No regulatory deficiencies were noted.

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

Kathleen Forsythe, LCSW                                    				Date: 11-20-24
Regulatory Consultant

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


summary: Visit conducted on 10-17-24. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):      1:00pm-4:30pm	DATE:  10-17-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Clinical Director
•	Clinical Coordinator
•	Second Shift Supervisor
•	Youth Workers
•	Clinical Intern

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to obtain an update on the program and meet the new Clinical Director.

Topics discussed included:
•	Census: 5 female residents in the program after a discharge earlier today. An admission is scheduled for later this day.

•	Incidents in the past three months:
o	AWOL: 67
o	Police calls: 73 (majority for AWOL reporting)
o	Restraint: 0
o	EMS calls: 6

•	Incident Response Note: During the past quarter Licensing responded to one incident and completed an Incident Response Note. The incident occurred on 10-9-24 and involved a client allegation of abuse.

•	Personnel:
o	Staff vacancies:1 full time first shift, 3 part time second shift and one part time third shift vacancy.
o	New Clinical Director began employment late last month.
o	New Clinical Intern from UCONN started last month; placement runs through June 2025.
o	Second shift supervisor is scheduled for Tuesday-Saturday.
o	New position guidance binders for Residential Manager, Clinical Director, Clinical Coordinator, Shift Supervisor.
o	Monthly 1:1 coaching meetings with direct care staff by Residential Management.
o	Brief interview with a direct care staff.

•	Training:
o	Restorative Justice training continues, Clinical Director scheduled to attend next month.
o	Four staff currently enrolled in DCF Medication Administration training.
o	TCI train-the-Trainer scheduled for 11-1-24 for Program Manager.

•	Programming:
o	Client reward program.
o	Restorative Justice techniques having positive impact with clients.
o	Halloween celebration activities.
o	Bi-monthly leadership dinner with clients on weekends.
o	Structured client scheduling.

•	Milieu Observation; brief conservations with two clients.

•	Physical Plant:  See 'Area of Regulatory Non-compliance' below.
o	All areas appeared organized and clean with seasonal décor displayed in common areas.
o	Bedrooms neat and organized.
o	Large room on first floor reorganized, numerous couches removed, conference room table and chairs installed.
o	Second floor living room reorganized; excess furniture removed.
o	Numerous interior doors are in need of cleaning.
o	Privacy film added to front stairwell window.
o	Kitchen layout rearranged; new oven installed last month.
o	Freezer chest in second floor storage room is in need of defrosting.
o	Loose headboards found on beds in several bedrooms.
o	Reviewed posted staffing schedule with medication certified staff assigned to each shift.
o	Reviewed posted meal menu; food storage discussed.
o	Outer pane of double-paned window in 2nd floor bathroom observed shattered; windowsill full of broken glass; unfinished wall section observed next to heating element.
o	Broken blinds observed on two windows in second floor front stairwell.
o	Large stain observed on carpeted front stairs leading to 3rd floor.
o	No telephone observed on third floor.
o	Loose or missing drawer pulls observed on dressers in bedrooms.
o	Loose carpet squares in bedroom D as well as numerous holes observed on the wall.
o	Hole observed in siding outside rear entrance door.

Areas of regulatory non-compliance identified during this visit:
17a-145-63	Chief Administrative Officer.
o	Outer pane of double-paned window in 2nd floor bathroom observed shattered; windowsill full of broken glass; unfinished wall section next to baseboard heating element.
o	Broken blinds observed on two windows in second floor front stairwell.
o	Large stain observed on carpeted front stairs leading to 3rd floor.
o	Loose carpet squares in bedroom D as well as numerous holes observed on wall.
o	Hole observed in siding outside rear entrance door.

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

Kathleen Forsythe, LCSW                    				Date: 10-18-24
Regulatory Consultant

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

Cc: 	Residential Director
Program Manager
File|


summary: Visit conducted on 7-23-24. 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 Bridge Family Centers- Freymann House STTAR program

TIME OF VISIT (FROM - TO):      10:00am-2:15pm               	DATE:  7-23-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Residential Director
•	Clinical Director
•	Clinical Coordinator

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to meet with the new Program Manager and Clinical Coordinator. The meeting was also attended by the Residential Director and the new Clinical Director.

Topics discussed included:
•	Census: 6 female residents in the program; one client on an over-age waiver scheduled for discharge in early August.
•	Personnel:
o	Staff vacancies - 2 full-time and 7 part-time staff vacancies are filled with part time or perdiem staff, or temp agency staff when needed. Manger reported the program currently uses temp agency staff an average of 2-3 shifts per week.
o	New Program Manager began employment in June.
o	New Clinical Director began employment this week.
o	Second Shift Supervisor position added to the house; position filled last month.
o	Discussed staff training activities.
o	A semiannual personnel file review was conducted on 6-28-24 at The Bridge HR office by a Regulatory Consultant. Two files were reviewed. No regulatory deficiencies were noted.
•	Programming.
•	Discussion on Licensing Regulation Compliance Plan Follow-up: treatment plans, physical plant.
•	Milieu Observation: One client observed napping in living room with staff present, and two clients observed napping in bedrooms after lunch.
.
•	Physical Plant: 	See 'Areas of Regulatory Non-compliance' below.
o	All areas appeared organized and generally clean.
o	New bed and dresser purchase; new area rugs placed in bedrooms.
o	Stairwell nooks free of objects.
o	Numerous interior doors are in need of cleaning.
o	Freezer chest in second floor storage room is in need of defrosting.

Areas of regulatory non-compliance identified during this visit:
17a-145-73	Sleeping Accommodations.
1.	Window coverings (shades, curtains, etc.) for client privacy are missing from bedroom windows in rooms C and G.

17a-145-74	Lavatory facilities. Toilet articles and linens.
1.	Paper towels are missing from the third-floor bathroom.
2.	Mold present in shower frame in third floor bathroom.

17a-145-85	Housekeeping equipment and supplies.
1.	Numerous containers of cleaning supplies were observed unsecured in a third-floor bathroom vanity, some in unmarked containers.

17a-145-98	Case records. Reports. Confidentiality.
1.	Several client case records were observed in an unlocked cabinet next to the first-floor entry.

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

Kathleen Forsythe, LCSW                                           				Date: 7-25-24
Regulatory Consultant

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


raw_content:
April 8, 2024

Ms. Margaret A. Hann
Executive Director
The Bridge Family Center, Inc.
1022 Farmington Ave.
West Hartford, CT 06107

Re: Freymann House STTAR Relicensing Inspection 2024
Licensing Consultants: Kathleen Forsythe, Amita Patel

Dear Ms. Hann,

On April 3rd and 4th, 2024, a biennial re-licensing inspection was conducted for the Freymann House temporary shelter program, located at 1019 Farmington Ave., West Hartford, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Child Caring Regulations 17a-145-48 through 17a-145-124, the DCF Medication Administration Guidelines, and the DCF Nursing Standards.

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

The areas of regulatory noncompliance are as follows:

17a-145-61	Written Policies and Procedures.
•	Evidence of the Executive Director's annual review in 2022 for required policies was not made available for review.

17a-145-73	Sleeping Accommodations.
•	Four of five occupied bedrooms were observed in messy, cluttered condition, including debris on the floors, empty food wrappers in one room, and an unfinished sandwich in another room.
•	All six bedrooms contain carpeting that is dirty and stained, with carpet tiles not affixed to the floor in a bedroom on the third floor.
•	A closet in a second-floor bedroom does not contain any shelving. Personal items were observed stored on the floor of the closet.
•	A dresser in a second-floor bedroom contains a broken handle.

17a-145-74	Lavatory Facilities. Toilet Articles and Linens.
•	The hot water temperature at the kitchen sink was recorded at 149°F and 151°on two consecutive days, which exceeds Department of Public Health Code 19a-495-551 requiring water temperatures at sinks to register between 110°F and 120°F.
•	Paper towels in a first-floor bathroom were not placed on a holder or dispenser to reduce incidents of contamination.
•	The sink in the third-floor bathroom is stained and missing the drain stop.
•	The shower frame in the third-floor bathroom contains mold.

17a-145-75	Health and Medical treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, Medicines, and Instruments. Sick Room, Telephone.
•	Evidence was not found of a program nurse signing off on transcriptions in one case record (MS) for March 2024.
•	A copy of the DCF Medication Administration Handbook was not present in the program.

17a-145-76	Kitchens, Equipment, Food-Handling.
•	The exterior of kitchen cabinets contains grime build-up, and the interior of food storage cabinets are in need of cleaning.
•	The bases of the sink cabinet and the trash cabinet are in deteriorated condition.
•	Knobs are missing on two kitchen cabinets.

17a-145-86	Instructions in Safety Procedures. Supervision.
•	Fire drill evacuation documentation for the licensed period indicates numerous missing reports:
?	2022: A second shift drill in the 2nd and 4th quarters.
?	2023: A first shift drill in the 3rd quarter, a second shift drill in the 4th quarter, and a third shift drill in the 2nd quarter.
?	2024: A first shift drill in the 1st quarter.

17a-145-96	Discharge of a Child.
•	A discharge summary report in one record (SH) contains an incorrect admission date.

17a-145-98	Case Records. Reports. Confidentiality.
Six open case records were reviewed. The following deficiencies were noted:
•	Family, social and health histories are missing in two records (MarS, MadS). This information is very limited in two other records (AE, GC).
•	Evidence that individual and group therapy sessions were consistently delivered or received with the frequency and/or duration listed on treatments plans was not found in case records.
•	One record (MarS) did not contain evidence of individual therapy sessions from 9-18-23 to 10-12-23, and 11-6-23 to 12-12-23. Evidence was not found that group therapy sessions were provided to this same client from 9-18-23 to 12-12-23.
•	Monthly treatment plans are not consistently signed by clients.
•	A March 2024 treatment plan was not found in one record (MadS).
•	The comprehensive assessment to be completed after intake is not signed or dated by the author in two records (MarS, AE).
•	Evidence of a licensed clinician consistently co-signing clinical notes written by student interns was not found in records reviewed.

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

Once the Licensing Unit has reviewed and accepted the completed Licensing Regulation Compliance Plan and has determined that your agency is in compliance with the regulations, a decision on the issuance of a regular twenty-four month license for the program will be made.  Until DCF makes this decision, the current license will remain in effect. Should you have any questions or comments regarding the contents of this report please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe, LCSW
Regulatory Consultant
Dept. of Children and Families

cc: File
     Director of Residential Services
     Program Director|


summary: Visit conducted on 2-22-24. No compliance issues identified. Implemented 1 corrective actions.

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

                                                            Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The Bridge Family Centers- Freymann House STAR program

TIME OF VISIT (FROM - TO):      12:30pm-3:15pm                    DATE: 2-22-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Director of Residential Services
•	Youth Worker
•	Clients (3)

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to meet with the Program Manager and Director of Residential Services for a program update and to tour the physical plant.

A meeting was held with the Program Manager and Director of Residential Services. Discussion included:
•	Census: 6 (5 females and one transgender female). One client currently in detention, one client at a medical appointment.
•	Staffing: one full time and three part time staff vacancies.
•	Status update on scheduled installation later this month of additional video cameras on exterior, 1st floor, interior stairwells, and 3rd floor. Discussion on frequency of management reviewing video footage for quality assurance; recommendation of documenting video review process.
•	Unannounced visits by managerial staff on weekends and third shift.
•	Restorative Justice initiative update: Clinical Coordinator completed phase one training; 1-2 direct care staff scheduled to attend training next week; daily check-in group improved attendance by youth;  data collection submission to DCF.
•	Recent Exceptional Circumstances forms submitted to DCF Risk Management.
•	Discharge planning for current residents; some referrals to YASS homes.
•	New Behavioral Intervention Specialist (BIS).
•	Snow removal by a contractor.

Milieu Observation:
•	Three residents observed in the program during visit; transportation company was 'no-show' for one client's school transport; one client returned from school early due to illness.
•	Residents observed in living room with one direct care staff.
•	Brief client Interviews.
.
Physical Plant:
•	Managerial staff facilitated tour of physical plant.
•	All areas appeared clean and organized; beds are made and bedrooms are organized.
•	Discussion on future furniture purchases.
•	Bedroom closet rods scheduled for reinstallation; hooks removed from bedrooms; closet shelves repaired.
•	Second floor bathroom scheduled for complete renovation next week; discussed supervision plan for utilization of 1st and 3rd floor bathrooms during renovation; damaged ceiling in 3rd floor bathroom will also be repaired.
•	Work order submitted to reverse basement doorknob to prevent unauthorized access.
•	Personal items and clothing organized in client bedrooms.
•	Minor damage to bedroom dresser surfaces from hygiene products.
•	Loose carpet tiles in one 3rd floor bedroom; proposed plan to replace flooring.
•	Discussion on appearance of recyclable collection area in nook off of front stairwell.

Meeting held with the new Director of Residential Services. Topics discussed included:
•	DCF biennial relicensing inspection scheduled for April 2024.
•	Thorough review of documents required for application to renew the home's child caring facility license; Biznet.
•	Personnel file requirements for interns.
•	Out-of-state CPS checks required for applicants who lived in another state in the 5 years prior to applying for employment.
•	Policy manual format; required policies for child caring facilities.
•	Consultant from CSI continues to work with the program through summer 2024.

Corrective Actions implemented as a result of previous visit: Service development plan submission to address regulatory citations noted in Licensing visit last month is pending.

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.  - No service development plan is required following this Licensing visit.

Kathleen Forsythe, LCSW                                                  				Date: 2-23-24
______________________________
Regulatory Consultant

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


summary: Visit conducted on 1-25-24. 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 Bridge Family Centers- Freymann House STAR program

TIME OF VISIT (FROM - TO):      12:05pm-2:10pm                    DATE: 1-25-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Program Manager
•	Clinician
•	Youth Workers (2)
•	Clients (2)

List of Areas / Topics covered during visit:  This was an unannounced Licensing visit to meet with the Program Manager for a program update and to tour the physical plant.

A meeting was held with the Program Manager. Discussion included:
•	Census: 5 females, with one client currently on AWOL status.
•	Staffing:
    o	Vacancies: 4 part time weekends positions.
    o	New Behavior Intervention Specialist began position since last Licensing visit.
    o	New Clinician began position this week; introduction.
    o	Two clinical interns; duties.
•	Corrective Action Plan (CAP) put in place in November 2023 to address program concerns was accepted by the Department yesterday 1-24-24.
•	Budget for monthly client activities.
•	Anticipated installation of additional video cameras on exterior, 1st floor, interior stairwell, and 3rd floor.
•	Programming: daily group, life skills group, status of Restorative Justice model initiative; site visit from consultant.
•	Discharge planning for current residents.
•	Status of two DCF investigations - staff returned from leave; final reports have not been issued.
•	School attendance by residents has improved since Christmas break.

Milieu Observation:
•	Two residents present in the program during visit.
•	One resident in living room with staff and observed preparing lunch; one resident in her bedroom. Both residents refused to attend school today.
•	Part time nurse S. was in the program during the visit.

Client Interviews:
•	Two clients were interviewed separately.
•	Both clients reported that they are unsure of their discharge plans.

Physical Plant: 	Youth worker T.  facilitated a tour of the physical plant. See Areas of Regulatory Non-compliance below.
•	All three floors and the basement were toured.
•	Common areas (kitchen, living room, classroom) appeared clean and organized.
•	Five bedrooms assigned to residents appeared messy with unmade beds.
    O 	Assigned bedrooms contained large amounts of personal effects piled in the bottom    of closets and on bedroom floors.
    O 	Dressers are present in bedrooms however hangers are few in quantity or missing in closets.
    O 	Broken closet shelf observed in bedroom B.
    O 	Cloth mattresses do not contain mattress covers.
    O 	Boxing gloves observed tied to overhead sprinkler pipe in a second floor bedroom.
    O 	Headboard is loose on bed in room G.
    O 	Two bedrooms on third floor are extremely warm in temperature; air conditioners in rooms available for client use.
•	Bathrooms on the second and third floors do not contain paper towels; toilet paper missing from the third-floor bathroom; two hair appliances resting on sink in third floor bathroom; cracked tile floor in second floor bathroom; mold on shower door in third floor bathroom; ceiling in 3rd floor bathroom is peeling. Both client bathrooms are in need of cleaning.
•	Knob on basement door should be reversed to prevent client access.
•	Client chore chart, recreation schedule, and January menus posted.
•	Med admin area in storage closet observed. Medication administration certified staff roster needs updating.
•	Freezer chest in storage room is need of defrosting due to ice build-up.
•	Numerous cleaning tools (mops, bucket, etc.) stored with recyclables in vestibule on second floor front stairwell is in need or organization.
•	Explanation of shift log documentation.

Corrective Actions implemented as a result of previous visit: A service development plan (SDP) was submitted on this date following a December 2023 personnel file review. The SDP is not accepted and is pending further follow up by the agency.

Areas of regulatory non-compliance identified during this visit:
17a-145-68       	Heating Ventilation, Lighting.
1.	The ceiling in the third-floor bathroom is damaged/peeling.

17a-145-73       	Sleeping Accommodations.
1.	Boxing gloves were observed tied to an overhead sprinkler pipe in a second-floor single bedroom.

17a-145-74       	Lavatory Facilities. Toilet Articles and Linens.
1.	Bathrooms on the second and third floors do not contain paper towels at the sinks.
2.	Toilet paper is missing from the third-floor bathroom; Toilet paper is not on a  holder in first floor bathroom.
3.	Tile floor in second floor bathroom is cracked in front of the shower.
4.	Mold is present on the shower door in the third-floor bathroom.

17a-145-90       	Clothing. Storage.
1.	Storage receptables for resident clothing are inadequate in resident bedrooms as evidenced by large amounts of personal effects piled in the bottom of closets and on bedroom floors and an insufficient hanger supply observed in closets.

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: 1-26-24
______________________________
Regulatory Consultant

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