summary: Visit conducted on _____3/25/24__________. Visit covered 6 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

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

TIME OF VISIT (FROM - TO):       __9:45am to 11am___               DATE: _____3/25/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	PD
	LMHT
	MHT/S

List of Areas / Topics covered during visit:
This is an unannounced visit.
•	Census is 6.  6 females placed.
•	PD reports the previous RN resigned and the RN supervisor provides medical coverage until a new RN is hired.
•	Program reports they have 6 medication certified staff, and one close to being certified, making it 7.
•	At the time of the visit, youth were observed upstairs working with school liaison.  It was quiet and appropriate.
•	Physical plant review completed and no concerns.
•	Medication review completed.  See below.

Corrective Actions implemented as a result of previous visit:
The agency's Policy and Procedure require the CPR and CPI training be completed within 90 days of hire.

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

•	At the time of the licensing visit, the designated staff member assigned to administer medication had already "signed out" the medication key exchange signature page at the beginning of the shift rather than the end of the shift where the next staff member is handed the keys. This is a citation; staff are instructed to sign out the medication keys at the end of their assigned shift when handing the keys to another medication certified staff member.
•	An open basket on the top shelf of the medication storage is used to store a variety of items 1) an unidentified white pill, found cut in half, and 2) one unidentified yellow pill found in a small envelope. This is a citation as both pills are unidentified and not secure.  The program did not follow its own policy for safe storage of medication.

1/10/2024 six month personnel file review.
6 month review 1/26/23 to 6/30/23:
CPR:
   D.S. no evidence of CPR certification.
   T.A. completed training more than 90 days from hire.

Restraint training (CPI):
   D.S. no evidence of restraint training.
   T.A. completed training more than 90 days from hire.

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,                                    4/9/24
Regulatory Consultant                                   Date

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

regulation:
CPR:
D.

description: S. no evidence of

regulation: D.

personnel: PD LMHT MHT/S


state: CT

facility_name: Discovery Practice Management, Inc. / Fairfield

summary: Visit conducted on _____1/10/24__________. Visit covered 2 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

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

TIME OF VISIT (FROM - TO):       __10pm to 12pm___               DATE: _____1/10/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	HR

List of Areas / Topics covered during visit:
•	Virtual 6 month personnel review completed for current and terminated employees for time period 7/1/23 to 1/10/24.
o	Four files reviewed. Two current and Two terminated.
•	6 month personnel file review completed for time period 1/26/23 to 6/30/23.
o	Three files reviewed.  Three current and one terminated.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
The agency's Policy and Procedure require the CPR and CPI training be completed within 90 days of hire.

6 month review 1/26/23 to 6/30/23:
CPR:
   D.S. no evidence of CPR certification.
   T.A. completed training more than 90 days from hire.

Restraint training (CPI):
   D.S. no evidence of restraint training.
   T.A. completed training more than 90 days from hire.

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,                                    1/17/24
Regulatory Consultant                                   Date

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

description: S. no evidence of


summary: Visit conducted on ____12/14/23_____. 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: ____Discovery Practice Management / Fairfield GH __________

TIME OF VISIT (FROM - TO):       __1pm  to 2:30pm___               		DATE: ____12/14/23_____

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Territory Operations Manager

List of Areas / Topics covered during visit:
•	Census is 5.  LBC 6.  All female.
•	Physical plant inspection of the Group Home. No concerns.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Met new Program Director of the program.
•	Discussed staffing of shifts.  No vacancies.
•	Reviewed and discussed the Policy and Procedure for Client Rights.

Corrective Actions implemented as a result of previous visit:
No SDP from previous visit.

Areas of regulatory non-compliance identified during this visit: No SDP required.
No SDP 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,                                    12/15/23
Regulatory Consultant                                   Date

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

type: general

description: No SDP required. No SDP required.


summary: Visit conducted on ____9/19/23__________. 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: ____Discovery Practice Management / Fairfield GH __________

TIME OF VISIT (FROM - TO):       __1:30pm  to 2:30pm___               		DATE: ____9/19/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	RN

List of Areas / Topics covered during visit:
•	Census is 5.  LBC 6.  Four females and one male.
•	Physical plant inspection of the Group Home. No concerns.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts.  No vacancies.
•	Residents observed assisting staff putting groceries away before they went into group session.
•	Medication Administration reviewed with RN. No concerns.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-48. Definitions.                            				Section(e)
Program did not adhere to this regulation.  Completed.

Section 17a-145-58. Waiver of requirements.
Program did not address this regulation.  Completed.

Areas of regulatory non-compliance identified during this visit: No SDP required.
No SDP 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,                                    11/22/23
Regulatory Consultant                                   Date

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

description: No SDP required. No SDP required.

personnel:
Program Director
RN


summary: Visit conducted on _____6/8/23__________. Visit covered 5 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

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

TIME OF VISIT (FROM - TO):       __1pm to 2:30pm___               DATE: _____6/8/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director

List of Areas / Topics covered during visit:
•	Census is 6.  LBC 6.  Five females and one male.
•	Physical plant inspection of the Group Home. No concerns.
•	Discussed the programing challenges and resident's treatment and compliance.
•	One case reviewed. See below.
•	Discussed staffing of shifts. Program has two clinicians, but one resigned. Clinician is covering, but stated a new clinician is hired and soon to begin working at the Group Home.

Corrective Actions implemented as a result of previous visit:
NO SDP from last visit.

Areas of regulatory non-compliance identified during this visit: No SDP required.
Section 17a-145-48. Definitions.                            				Section(e)
Program did not adhere to this regulation.

Section 17a-145-58. Waiver of requirements.
Program did not address this regulation.

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

Thomas S. Cuchara,                                    6/8/23
Regulatory Consultant                                   Date

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


raw_content:
John Peloquin, CEO							             3/3/23
Discovery Practice Management
4281 Katella Avenue, Suite #111
Los Alamitos, CA  90720

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

Dear Mr. Peloquin,

On 1/26/23 and 1/27/23 a biennial re-licensing inspection was conducted at 615 Mine Hill Road, Fairfield, CT.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Service Development Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Service Development Plan as well.  Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a plan of a Service Development Plan.

Section 17a-145-64. Personnel policies and procedures.
Evidence:  Three personnel files reviewed.
Restraint:  One file did not have evidence of restraint training. M.V.

Medication Administration:
DCF Reg: 17a145-75 (d) and 17a -6(g) - 16 (c)
Evidence:
1.	Based on the review of the training records the facility failed to provide quarterly training from 2021 and 2022.
•	No documentation found that the med certified staff attended training for two years.
2.	Program did not submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management.

3.	Based on the review of the DCF Data entry system the facility failed to submit the monthly summaries from 07/2021 to January 2023.

4.	Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employee file.

5.	Based on the review of the records the facility failed to do Medication Administration Skills Once a year.

6.	 The following medication administration certified staff members' annual skills verification not done. M.C., L.R., M.V., N.R., A.F.

7.	Quarterly Review of Policies and Procedures Quarterly.  The supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration.
•	Based on the review of the records the facility failed to review the quarterly policy.
RN Signature:  Missing-January 2022.
MD and RN signature missing for 10/01/22 and 01/26/21.

8.	Mandatory Annual Epi-pen & Inhaler & Training for all staff
Based on the review of the training records the facility failed to provide annual epi-pen-asthma training.
•	This training must be provided at least annually and whenever necessary to maintain a safe environment for children.
•	Documentation shall be maintained listing staff who have been successfully trained and deemed competent to administer Epi-pens and emergency inhalers.
•	Annual epi-pen & asthma training missing in 2021 & 2022

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

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

Sincerely,

_______________________________________
Thomas S. Cuchara,
Regulatory Consultant

Copy: file|

report_type: unstructured


summary: Visit conducted on _____12/27/2022____. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management_________________

 TIME OF VISIT (FROM - TO):       _______1pm_______________               DATE: _____12/27/2022____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
JG	Program Director
MT	Medical Quality Manager
CB	RN Supervisor Fairfield and Stamford
LR	Program Administrator

List of Areas / Topics covered during visit:
•	Census is 6.  5 females & 1 male.  LBC 6.
•	Physical plant inspection of the Group Home.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed on-going training with staff.
•	Discussed staffing of shifts. No staff vacancies.

Corrective Actions implemented as a result of previous visit:
No SDP from previous visit.

Areas of regulatory non-compliance identified during this visit:
   	No SDP 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              			12/27/2022
Regulatory Consultant                                   Date

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

description: No SDP required.


summary: Visit conducted on _____9/22/2022____. Visit covered 8 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management- Fairfield GH_______________

 TIME OF VISIT (FROM - TO):       _______12pm_______________               DATE: _____9/22/2022____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
LR	Program Administrator

List of Areas / Topics covered during visit:
•	Census is 6.  6 females.  LBC 6.
•	Physical plant inspection of the Group Home.  LR noted all bedrooms have been painted, new dining room table, carpets, and furniture for the living room.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed on-going training with staff.
•	Discussed staffing of shifts. LR reports one part-time open vacant position opened.
•	One client discharge record reviewed and in compliance.

Corrective Actions implemented as a result of previous visit:
No SDP from previous visit.

Areas of regulatory non-compliance identified during this visit:
   	No SDP 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              			11/10/22
Regulatory Consultant                                   Date

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

description: No SDP required.


summary: Visit conducted on _____6/27/2022____. Visit covered 7 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management_________________

 TIME OF VISIT (FROM - TO):       _______1:30pm_______________               DATE: _____6/27/2022____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
LR	Program Administrator

List of Areas / Topics covered during visit:
•	Census is 6.  6 females.  LBC 6.
•	Physical plant inspection of the Group Home.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed on-going training with staff.
•	Discussed staffing of shifts. LR reports no vacancies. However, LR is the new PD.
•	One client record reviewed and in compliance.

Corrective Actions implemented as a result of previous visit:
No SDP from previous visit.

Areas of regulatory non-compliance identified during this visit:
   	No SDP 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              			8/8/2022
Regulatory Consultant                                   Date

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

description: No SDP required.


facility_name: Discovery Practice Management, Inc. / S.Port / GH

summary: Visit conducted on 3/3/2026. 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: Center for Discovery - Southport Eating Disorder Program

TIME OF VISIT (FROM - TO):     11:00 am - 11:45 am           		DATE:  3/3/2026

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Director of Operations

List of Areas / Topics covered during visit:

This was an announced quarterly Licensing visit to transition assigned DCF Regulatory Consultants and tour the physical plant.
-
A meeting was held with the Director of Operations. Topics discussed included:
•	Census: 0 / LBC=6
•	Staff vacancies: Three part-time positions
•	Staffing: 11 Full-time staff, 4 Part-time and 3 Per Diem
•	Staffing Levels: Director of Operations will ensure two staff members, other than nursing, are present during all three shifts.
•	Nursing: Director of Operations confirmed LVNs are no longer being utilized as direct care staff.
•	Administration Changes: The former CEO is no longer with the agency and they are seeking candidates for this position.  The COO is the current acting CEO.

Physical Plant: Director of Operations facilitated the tour of the physical plant.  There were no citations identified.

Corrective Actions: N/A

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

Please submit a regulation compliance plan to address the above-mentioned 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.

Lori Read, LMSW				                             Date:  3/3/26
Regulatory Consultant

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


summary: Visit covered 13 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: Discovery Practice Management/ Southport Group Home

TIME OF VISIT (FROM-TO) 12:35am to 1:30pm:             DATE: November 21, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Director of Operations

Areas / Topics covered during visit:

•	Census: The program had 2 males, and 3 females placed at the facility at the time of the quarterly visit.
•	Admissions: In the last quarter, the program confirmed that there were three new admissions.
•	Discharges: The program reported that in the last quarter, there were 2 planned discharges.
•	Staffing: The facility staffing consists of 9 full-timers,2 part-timers and 1 per-diem employee.
•	Staff vacancies: The program reported that in the last quarter, it had 2 full-time and three part-time vacancies.
•	Staff hires: The program confirmed that there were no new hires in the last quarter.
•	Physical plant: A walkthrough of the building was conducted with program staff to evaluate the group home's compliance with regulatory standards.

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

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

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

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

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

Penny Woodward, LCSW                         December 4, 2025
Regulatory Consultant                                          Date

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


summary: Visit conducted on ____7/22/25__________. 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: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __1:15pm-1:30pm___               DATE: ____7/22/25__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Operational Manager
	Regulatory Consultant-DCF

List of Areas / Topics covered during visit:
•	Announced visit to group home.
o	Purpose of visit to introduce Regulatory Consultant, Penny Woodward.
•	Census is 5. LBC- 6.  4 females & 1 male. 3 from Ct and 2 from NY.
•	Staffing:
o	Monday-Saturday 2-10pm open (hiring to replace current employee)
o	Sunday and Monday 6am-2pm (filing with On-Call staff)

Corrective Actions implemented as a result of previous visit:

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

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

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

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

description: No RCP required.


summary: Visit conducted on ____6/6/25__________. 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: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __2pm-3pm___               DATE: ____6/6/25__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Executive Director

List of Areas / Topics covered during visit:
•	Announced visit to group home.
•	Census is 5. LBC- 6.  5 females.
•	One education liaison position opening.
•	The RN has left, but her position is immediately covered by another RN from one of the adult programs.  One of the LPN's that works in the program recently graduated from nursing school will soon assume duties.
•	Clients occupied and kept busy with group that staff facilitated.  No concerns.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-98. Case records.
Evidence: Six client files reviewed specifically for ICPC documentation.  Corrected
•	Out of state client files reviewed did not find evidence the ICPC form was submitted prior to admission.  Three client files did not have evidence in the file of the ICPC form which is supposed to be submitted at time of discharge.  The ICPC forms are routinely submitted after the clients admission.

Physical Plant: The basement has an area where youth go for activities and clinical sessions.  The rug was found to be in poor condition with numerous stains on all the steps and main floor.

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

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

Thomas S. Cuchara,                                    6/25/2025
Regulatory Consultant                                   Date

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

description: No RCP required.


summary: Visit conducted on ____2/25/25__________. Visit covered 5 main areas/topics. Found 2 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: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __10:10am to 11:10am ___               DATE: ____2/25/25__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Executive Director

List of Areas / Topics covered during visit:
•	Announced visit to group home.
•	Census is 6. 6 females. Four youth from CT, one from N.J. and 1 from Rhode Island.
•	Staffing: 1st shift has one part-time open position. 2nd shift no vacant position.  3rd one part time position is in the process of boarding.
•	Clients occupied and kept busy with group that staff facilitated.  No concerns.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-98. Case records.
Evidence: Six client files reviewed specifically for ICPC documentation.
•	Out of state client files reviewed did not find evidence the ICPC form was submitted prior to admission.  Three client files did not have evidence in the file of the ICPC form which is supposed to be submitted at time of discharge.  The ICPC forms are routinely submitted after the clients admission.

Physical Plant: The basement has an area where youth go for activities and clinical sessions.  The rug was found to be in poor condition with numerous stains on all the steps and main floor.

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,                                    2/28/2025
Regulatory Consultant                                   Date

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


summary: Visit conducted on ____12/20/24_________. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 3 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: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __1pm to 2pm _                                             DATE: ____12/20/24_________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	OP- Operations Manager
	Executive Director

List of Areas / Topics covered during visit:
•	Announced visit to group home.
•	Census is 6. 4 females and 2 male.
•	Staffing: all shift are stable, but program is looking ot hire one LPN tech.
•	Program was clean and clients occupied and kept busy with group that staff facilitated.  No concerns.
•	11/20/24, an incident occurred where one youth ate food, she did not know she was allergic to.  The RN on duty administered an EPI-Pen.  The Ambulance was called and arrived but did not need to transport her to the hospital.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-64. Personnel policies and procedures.  Completed.
•	Four staff did not have evidence of CPR certification.
•	Three staff did not have evidence of CPI certification.

Areas of regulatory non-compliance identified during this visit:

No Regulatory Compliance Plan 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,                                    12/20/24
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.


raw_content:
John Peloquin, CEO								9/20/24
Discovery Practice Management
4281 Katella Avenue, Suite #111
Los Alamitos, CA  90720

Re: Licensing Inspection for Southport GH
Regulatory Consultants: Tom Cuchara & Jim Funaro

Dear Mr. Peloquin,

On 9/18/24 a biennial re-licensing inspection was conducted at 1320 Mill Hill Road, Southport, CT.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Regulatory Compliance Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Regulatory Compliance Plan as well.  Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a plan of a Service Development Plan.

Section 17a-145-64. Personnel policies and procedures.
•	Four staff did not have evidence of CPR certification.
•	Three staff did not have evidence of CPI certification.

Once licensing has reviewed and accepted the Regulatory 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 call me at (860) 550-6310 or Kathy DiTuccio, Licensing Program Supervisor  KATHLEEN.DiTuccio@ct.gov / 860-398-1370).

Sincerely,

_______________________________________
Regulatory Consultant

Copy: file|


summary: Visit conducted on ____6/20/24__________. Visit covered 5 main areas/topics. Found 1 compliance issues. Implemented 2 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __1:15pm to 2:30pm___               DATE: ____6/20/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	LPN
	FM
PD

List of Areas / Topics covered during visit:
•	Announced visit to group home.
•	Census is 6. 6 females.
•	Staffing: Facility Manager resigned and the in-house milieu manager has taken over his duties.
•	Program was clean and clients occupied and kept busy with group that staff facilitated.  No concerns.

Corrective Actions implemented as a result of previous visit:
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.  While this is being noted as a citation, the issue was addressed during the visit.
(d) The facility shall permit only staff who have been fully instructed in the proper administration, expected and untoward effects, and contraindications to continued administration of a prescribed medicine or treatment to administer that medicine or treatment. The facility shall have a written policy specifying the criteria used for designating staff to administer medication and a written plan for training staff. The facility shall maintain a current, written roster of staff designated to administer medication. There shall be periodic reviews and updating of staff's knowledge about medication and other treatments and their administration.
•	At the time of the licensing visit. The assigned staff member responsible for carrying the medications keys did not have the keys in her possession.  The program did not follow their own policy and procedure for securing the medication keys.  The medication keys are to be carried by the designated staff member at all times.  This is a citation.

From 1/10/2024 six month personnel file review.  COMPLETED
7/1/23 to 1/10/24
State Police background check:
T.S. & S.F. no evidence of background check
L.P. State Police check was done after date of hire.
A.K. State Police check was done after date of hire.

1/26/23 to 6/30/23
Policy & Procedure:
C.C. & A.B. signed late.  Per Policy & Procedure the P&P is required to be signed within 3 days
of hire.

TB test:
A.B. completed more than 90 days after hire.

State Police:
                    A.B. & S.S. had evidence background check is late.

CPR:  Per Policy & Procedure CPR is required to be completed within 90 days of hire.
              A.D. no evidence of certification.
C.C., A.B., S.S., E.L., A.Q: certification was completed after 90 days of hire.

Restraint(CPI): Per Policy & Procedure Restraint training is required to be completed within 90 days of hire.
              C.C. & A.D. no evidence of have been trained.
              A.B & S.S. no evidence it was completed within 90 days of hire.

Areas of regulatory non-compliance identified during this visit:

No Regulatory Compliance Plan required.

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

Thomas S. Cuchara,                                    7/3/24
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.

personnel: LPN FM PD


summary: Visit conducted on ____1/10/24__________. Visit covered 2 main areas/topics. Found 7 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: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __10am to 12pm___               DATE: ____1/10/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	HR

List of Areas / Topics covered during visit:
•	Virtual 6 month personnel review completed for current and terminated employees for time period 7/1/23 to 1/10/24.
o	12 files reviewed. 12 current.
•	Virtual 6 month personnel file review completed for time period 1/26/23 to 6/30/23.
o	10 files reviewed.  7 current files and 3 terminated.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
7/1/23 to 1/10/24
State Police background check:
T.S. & S.F. no evidence of background check
L.P. State Police check was done after date of hire.
A.K. State Police check was done after date of hire.

1/26/23 to 6/30/23
Policy & Procedure:
C.C. & A.B. signed late.  Per Policy & Procedure the P&P is required to be signed within 3 days
of hire.

TB test:
A.B. completed more than 90 days after hire.

State Police:
                    A.B. & S.S. had evidence background check is late.

CPR:  Per Policy & Procedure CPR is required to be completed within 90 days of hire.
              A.D. no evidence of certification.
C.C., A.B., S.S., E.L., A.Q: certification was completed after 90 days of hire.

Restraint(CPI): Per Policy & Procedure Restraint training is required to be completed within 90 days of hire.
              C.C. & A.D. no evidence of have been trained.
              A.B & S.S. no evidence it was completed within 90 days of hire.

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,                                    1/17/24
Regulatory Consultant                                   Date

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

area_type: State Police background check

regulation: T.

description: S. &

regulation: C.

description: C. &

regulation: A.

area_type: State Police

description: B. &

description: A.

description: Restraint(

area_type: CPI)


summary: Visit conducted on ____12/14/23__________. Visit covered 9 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __10:15am to 12:15pm___               DATE: ____12/14/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Executive Director
	Facilities Manager

List of Areas / Topics covered during visit:
•	Census is 5.  LBC 6.  Five females.
•	One youth was discharged to home in good standing during the visit.
•	Physical plant inspection of the Group Home completed. No concern.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts. No vacancies. The program is looking to hire one LPN for on call to work 2nd shift.
•	Reviewed one case record and it is in compliance.
•	At the time of the visit youth were observed relaxing in the living room before lunch.  The house was quiet.
•	Staff observed getting lunch ready for residents.
•	Reviewed and discussed the Policy and Procedure for Client Rights.

Corrective Actions implemented as a result of previous visit:
Physical Plant.
•	The basement is frequently used by residents for therapy sessions and group. The Rug they walk on has a large stain.  It should be cleaned.  Completed.

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,                                    12/15/23
Regulatory Consultant                                   Date

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

description: No SDP

personnel:
Executive Director
Facilities Manager


summary: Visit conducted on _____9/26/23__________. Visit covered 8 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __11am to 11:20am___               DATE: _____9/26/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Executive Director

List of Areas / Topics covered during visit:
•	Census is 5.  LBC 6.  Five females.
•	Physical plant inspection of the Group Home. See below.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Discussed staffing of shifts. No vacancies.
•	One LPN position is open on 2nd shift and one Diet Tech for 2nd shift is hired.
•	At the time of the visit youth were observed spending time with staff eating snacks and preparing for a process group.
•	Fire Drills requested and sent via email for 2023 reviewed and found in compliance.
•	Reviewed and discussed the Policy and Procedure for Client Rights. Policy and procedure sent via email.

Corrective Actions implemented as a result of previous visit:
NO SDP from last visit.

Areas of regulatory non-compliance identified during this visit:
Physical Plant.
•	The basement is frequently used by residents for therapy sessions and group. The Rug they walk on has a large stain.  It should be cleaned.

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,                                    10/26/23
Regulatory Consultant                                   Date

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


summary: Visit conducted on _____6/6/23__________. 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: ____Center of Discovery / Southport __________

TIME OF VISIT (FROM - TO):       __9:50am to 11:20am___               DATE: _____6/6/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Executive Director
	Milieu Manager

List of Areas / Topics covered during visit:
•	Census is 4.  LBC 6.  Three females and one male.
•	Physical plant inspection of the Group Home. No concerns.
•	Discussed the programing challenges and resident's treatment and compliance.
•	Reviewed medication administration and found no concerns.
•	One case reviewed and found no concerns.
•	Discussed staffing of shifts. No vacancies.

Corrective Actions implemented as a result of previous visit:
NO SDP from last visit.

Areas of regulatory non-compliance identified during this visit: No SDP required.
  NO SDP for this visit.

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,                                    11/22/23
Regulatory Consultant                                   Date

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

description: No SDP required. NO SDP for this visit.

personnel:
Executive Director
Milieu Manager


summary: Visit conducted on 3/2/23. 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 / PROGRAM: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __1pm__________               DATE: 3/2/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
OT	Program Director
WS	Milieu Staff

List of Areas / Topics covered during visit:

•	Census is 5.
•	At the time of the visit there was one youth in the program.  He is a new admission.
•	Physical plant inspection was conducted and in compliance.
•	Discussed the programing, resident safety, juggling room challenges.
•	Discussed staffing of shifts. No staff vacancies on all three shifts.
•	Reviewed medication.
•	One case record reviewed.

Corrective Actions implemented as a result of previous visit: n/a

Areas of regulatory non-compliance identified during this visit:
Medication Administration:
•	The sheet used to document key exchanges calendar dates are predated.  The document has room for only signatures of staff handing the key off to the oncoming shift.  The document does not have sufficient space to accommodate multiple key exchanges for each shift.

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                           ___3/24/23_______
Regulatory Consultant                                   Date

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

area_type: Medication Administration

facility_name: Boys and Girls Village / STAR

personnel:
OT	Program Director
WS	Milieu Staff


raw_content:
John Peloquin, CEO							       11/3/2022
Discovery Practice Management
4281 Katella Avenue, Suite #111
Los Alamitos, CA  90720

Re: Licensing Inspection for Southport GH
Regulatory Consultants: Tom Cuchara & Penny Woodward

Dear Mr. Peloquin,

On 9/13/22 and 9/14/22 a biennial re-licensing inspection was conducted at 1320 Mill Hill Road, Southport, CT.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Service Development Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Service Development Plan as well.  Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance, but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a plan of a Service Development Plan.

Section 17a-145-64. Personnel policies  and procedures.
Evidence: 15 personnel files reviewed.
CPR: Missing CPR certification, OS, DL, AM, MG, JT
Restraint: missing KN, JT, OS,HB

Section17a-145-75. Health and medical treatment.				 section(b)
Evidence:
At the time of the licensing review there was no evidence the physician signed off on the medical policy and procedures.
DCF Regulation 17a-6(g)-15 (a - g)     Administration of the Medication Training Program.
Evidence:
1) Mandatory Training for All Staff • Annual Emergency Medication Administration - Epi-pens and Asthma Rescue Medication. • This training must be provided at least annually and whenever necessary to maintain a safe environment for children.
•	Violation 1
Based on the review of the training records the facility failed to provide annual EpiPen / inhaler training in 2021.
2)  Annual Observation of Medication Administration Skills Once a year the facility nurse must observe medication certified staff performing the DCF medication administration procedure. This must be documented using the DCF-2275 DCF Medication Administration Program Procedure Checklist and placed in the employees file.
•	Violation 2
Based on the review of the training records the facility failed to provide Annual Observation of Medication Administration Skills for one of the staff members.
•	Staff Member, A. P. missing the Annual Observation of Medication Administration Skills in July 2022.
3) DCF Medication Administration Regulation.
Submit a DCF-2272 Monthly Medication Administration Program Supervision and Review to DCF Risk Management.
•	Violation3
Based on the review of the DCF Data system the facility failed to provide DCF-2272 from June 2021 to July 2022.

4) DCF Reg: 17a-6(g) -16 (c): "Day programs and residential facilities shall provide continuing education on administration of medication to trained person staff members." Facility nurses and/or appropriate personnel must offer continuing education opportunities for DCF medication certified staff. The facility nurse must document on a quarterly basis all continued education opportunities offered in the past 3 months. See Forms section for suggested form to document quarterly offerings.
•	Violation4
Based on the review of the training records the facility failed to provide quarterly training in 2021 and 2022.
5) Quarterly Review of Policies and Procedures Quarterly, the supervising registered nurse or licensed medical person will document a review of the facility’s medication policies and a review of the continuing education offered related to medication administration. Forms for documentation of these reviews are available on line and in the Forms section of this handbook (see Quarterly Review of Medication Policy and Procedures by Licensed Nurse and Quarterly Review of Medication Administration Continuing Education).  Documentation of these reviews is to be kept at the facility and made available to the DCF upon request.
•	Violation 5
Based on the review of the policy records the facility failed to review the Quarterly Review of Policies and Procedures Quarterly.

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

Should you have any questions or comments regarding the contents of this report please do not hesitate to call me at (860) 550-6310 or 203-675-6975.

Sincerely,

_______________________________________
Regulatory Consultant

Copy: file|


summary: Visit covered 14 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: Discovery Practice Management/ Stamford Group Home

 TIME OF VISIT (FROM-TO) 11:30am to 12:15pm:             DATE: February 20, 2026

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Associate Vice President of Operations

Areas / Topics covered during visit:

•	Census: The program had 1 male, and 5 females placed at the facility at the time of the quarterly visit.
•	Admissions: In the last quarter, the program confirmed that there were twenty-eight new admissions.
•	Discharges: The program reported that in the last quarter, there were 7 unplanned discharges and 22 planned discharges.
•	Staffing: The facility staffing consists of 18 full-timers,5 part-timers and 2 per-diem employees.
•	Staff hires: The program confirmed that there were 5 new hires in the last quarter.
•	Medication: The program does not have any medication certified staff at the facility, and medication is administered by the nursing staff.
•	Personnel: Four employee records were reviewed on 2/17/26, and two records required but did not have the required out-of-state criminal background check results. At the time of the audit, documentation was not presented to confirm that the criminal checks had been requested.
•	Physical plant: A walkthrough of the building was conducted with program staff to evaluate the group home's compliance with regulatory standards.
•	SIU Reports: There were no reports in this quarter.

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

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

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

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

Penny Woodward, LCSW                         March 4, 2026
Regulatory Consultant                                   Date

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


summary: Visit covered 12 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: Discovery Practice Management/ Stamford Group Home

 TIME OF VISIT (FROM-TO) 11:00am to 12:30pm:             DATE: October 30, 2025

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Associate Vice President of Operations
Program Director

Areas / Topics covered during visit:

•	Census: The program had 4 males, and 7 females placed at the facility at the time of the quarterly visit.
•	Admissions: In the last quarter, the program confirmed that there were ten new admissions.
•	Discharges: The program reported that in the last quarter, there were 4 unplanned discharges and 16 planned discharges.
•	Staffing: The facility staffing consists of 9 full-timers,4 part-timers and 2 per-diem employees.
•	Staff vacancies: The program reported that in the last quarter, it had 2 full-time vacancies.
•	Staff hires: The program confirmed that there were 2 new hires in the last quarter.
•	Physical plant: A walkthrough of the building was conducted with program staff to evaluate the group home's compliance with regulatory standards.

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

Corrections implemented as a result of previous visit:
17a-145-73. Sleeping accommodations. The floor in bedroom one, located on the second floor, has been repaired.

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

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

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

Penny Woodward, LCSW                         November 17, 2025
Regulatory Consultant                                            Date

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


summary: Visit conducted on _____7/22/25__________. Visit covered 6 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       11:30am 12pm                  DATE: _____7/22/25__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Regional Director of Operations East Coast
	Program Director
	Regulatory Consultant-DCF

List of Areas / Topics covered during visit:
•	LBC 12. Census is 11.  7 females and 4 males.
•	Purpose of visit to introduce Regulatory Consultant, Penny Woodward.
•	At the time of the visit, the ceiling in the main living room is being repaired and repainted. Program also stated new furniture was purchased.
•	RN position was offered and start date as of 7/28/2025.
•	2 part-time positions opened that are currently being covered by per diem staff and techs from Fairfield or Southport. Onboarding one part time staff at the moment.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73.  Sleeping accommodations. UPDATE: Program has contracted with a carpenter to repair the floor. Program will provide sleeping accommodations for youth while repair is being made and consult with DCF.
Evidence: Condition of bedroom on second floor.
•	Second floor bedroom called 'Yellow Double Room' /Rm1, has two twin beds.  The floor repair continues to be a concern; the corner of the bedroom has sunken and no longer level. The program did make repair efforts which was accepted by licensing last quarter. However, during this inspection the floor evidence the floor is not level remains.  At the time of first licensure, the floor was level and did not present a concern.  The agency must evaluate the condition of the subfloor and make sufficient repairs to ensure the entire room's floor is level.  During this time only one youth will be allowed to sleep in this room.

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

Thomas S. Cuchara                                   7/22/25
Regulatory Consultant                                   Date

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

area_type:
DCF.
Evidence

regulation: Condition of bedroom on second floor.


summary: Visit conducted on _____5/7/25__________. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 2 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       11am to 1pm ___                 DATE: _____5/7/25__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Regional Director of Operations East Coast
	Operations Manager

List of Areas / Topics covered during visit:
•	LBC 12. Census is 8 females and 2 males 3/26/2027.
Met with the Operations Manager at the program and spoke by phone to the Regional Director of Operations East Coast by phone.
•	At the time of the visit the youth were in school, group and eating lunch.  Youth stated they like it at the program and love lunch.  Youth and staff interacted positively.
•	No vacant positions on all three shifts.
•	Program reports training since the most recent relicensing, CPI and CPR training for new staff will be completed within the first two weeks hire and included in the 'On Boarding' process.
•	Reviewed one incident with youth that required hospitalization and eventual discharge.  Reviewed the admission process with the RN, Regional Director.
•	Physical plant reviewed.  See below.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-76. Kitchen, equipment, food -handling.   Completed new refrigerator
Evidence:
•	The façade of the cabinets in the kitchen are in poor condition due to wear and tear. The carousel in the kitchen next to the stove is broken and needs to be repaired.
•	The kitchen stove is missing a protective cover which is used to cover the gas pipe to prevent someone from accidently kicking the pipe.
•	The refrigerator handle is broken and one of the door shelves is broken.
•	The freezer handle is broken, and staff report the seal is broken to. It is not being used.

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73.  Sleeping accommodations.
Evidence: Condition of bedroom on second floor.
•	Second floor bedroom called 'Yellow Double Room' /Rm1, has two twin beds.  The floor repair continues to be a concern; the corner of the bedroom has sunken and no longer level. The program did make repair efforts which was accepted by licensing last quarter. However, during this inspection the floor evidence the floor is not level remains.  At the time of first licensure, the floor was level and did not present a concern.  The agency must evaluate the condition of the subfloor and make sufficient repairs to ensure the entire room's floor is level.  During this time only one youth will be allowed to sleep in this room.

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                                   5/12/25
Regulatory Consultant                                   Date

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

corrective_actions:
76. Kitchen, equipment, food
handling. Completed new refrigerator


raw_content:
John Peloquin, CEO							2/27/2025
Discovery Practice Management
4281 Katella Avenue, Suite #111
Los Alamitos, CA  90720

Re: Licensing Inspection for Stamford GH
Regulatory Consultants: Tom Cuchara and Jim Funaro

Dear Mr. Peloquin,

On 1/214/25, 1/22/25 and 1/23/25 a biennial re-licensing inspection was conducted at 929 Newfield Avenue, Stamford, CT.  This inspection was conducted to determine the compliance of this facility with the Regulations for Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98, as well as the DCF Guidelines for the Administration of Medication by Certified Staff and the DCF Nursing Standards.  Below are listed the areas of regulatory non-compliance which were identified during the re-licensing inspection. Please review the areas identified and submit a Regulatory Compliance Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit Regulatory Compliance Plan as well.

Section 17a-145-64. Personnel policies and procedures.
Evidence:  Eighteen files reviewed.
CPR: Three files did not have evidence of CPR training 90 days after their date of hire.  E.M., A.E., D.C.

DCF Reg: 17a145-75 (d) and 17a -6(g) - 16 (c)
Evidence: Based on the review of the Policy and Procedure there is no evidence the medical policy and procedure was reviewed by physician and RN.

Section 17a-145-93. Medical, dental, and nursing care.
Evidence:  Based on the review of 5 of 6 client records there is no evidence the dental, vision and physical exams were found in the client's file.

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

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

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

Sincerely,

__Thomas S. Cuchara_______________________________
Thomas S. Cuchara
Regulatory Consultant

Copy: file|


summary: Visit conducted on _____11/6/24__________. Visit covered 11 main areas/topics. Found 9 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       9:30am to 1pm ___                 DATE: _____11/6/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Executive Program Director (EPD)
	Operations Manager

List of Areas / Topics covered during visit:
•	LBC 12. Census is 9. 4 males and 5 females.  License expires 3/26/2025.
•	Met with the EPD. Youth were in the process of going to their individual education tracks. Mood of unit calm but active with two 12year old males.  One female asked to speak with me about concerns regarding a 12-year-old peer making inappropriate statements.  She addressed her concern maturely.  I relayed this to EPD and OM who are already aware and will address the male peer's behavior clinically and behaviorally.
•	Seven Exceptional Circumstance reports received from the program for this quarter.
•	Program has reduced the staffing ratio on all three shifts.  See below.
•	Program has not had a RN physically on-site sine 9/6/24. See below.
•	Program has not hired a RN to replace RN that left 9/6/24. See below.
•	Program utilizes virtual RN to complete admission assessments.  See below.
•	Physical plant walk-through. See below.

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63.  Chief administrative officer.
Evidence:  The Discovery Practice Management, CA did not notify the DCF-Licensing of significant staffing changes to the supervision of youth and medical care of youth.
a)	Failed to notify and seek approval from the DCF Licensing before the staffing changes took place.  Programs are required to notify the department whenever significant staff changes are made.  Based on the application submitted the Group Home is licensed for 3:12 ratio on all three shifts.  DPM had increased the ratio on 2nd shift to 4:12 to accommodate the census (LBC 12) due to safety and acuity of the clients.  The building has four floors and utilizes all four during parts of day.  It is a challenge for staff to monitor and supervise youth during awake hours and still meet program clinical, education, recreation needs, safely.  At issue, DPM changed the staff ratio to 2:12 on 1st and 3rd shifts and 2nd shift will be 3:12.  Due to the mental health needs and mixed population (female/male) combined with staff expectations and physical plant challenges the loss of one staff has had a negative impact on staff's ability to provide a safe nurturing environment.  In addition, the program lost one clinician. Overall, the mental health acuity of clients admitted has not changed but gotten worse.   DPM must maintain the same staffing ratio regardless of census.  If the staff ratio needs to change the agency is required to notify the DCF Licensing unit for approval.
b)	Failed to notify the DCF Licensing of change in nursing coverage.  Stamford and Fairfield are using the Southport GH RN to conduct admission assessments.  The program utilizes virtual RN coverage and there is no plan to have a RN on site.  The RN last site 9/6/24.  The LPN completes assessments, and the RN completes her assessment virtually with the LPN or Mental Health Techs present.
c)	Staff report the acuity of patients admitted has risen and most are coming directly from a psychiatric hospital creating an unpredictable and unsafe environment as these changes are taking place.  The increase of Exceptional Circumstance Reports is increased and with several CPI holds increased reported.
d)	A refrigerator and Freezer are broken, and parts unavailable to fix or repair.  Staff use a small refrigerator located in the laundry room (which is locked) to get food. Residents are no longer able to get food on their own but must ask staff for snacks or other foods from the laundry room.

Section 17a-145-73.  Sleeping accommodations.
Evidence: Condition of bedroom on second floor.
•	Second floor bedroom called 'Yellow Double Room', has two twin beds.  The bed in the far-left corner, window side, of room is sunken several inches over the past several weeks.  Program reports this is very new and recently reported. Staff pointed out the main hallway on the second floor appears to be in a similar condition.  Also new.  Licensing advised staff to move youth to the other bed in the same room, but level.  Even though the room size is large enough for 2 youths and beds; only one youth can sleep in this room until the floor is replaced or repaired. The agency should immediately investigate the safety of the floor and any potential impact to the program.  In addition, the agency must make appropriate accommodations if the remaining youth should have to move from the room and relocate elsewhere in the building up to and including supervision.  DCF Licensing must be notified of any plan and approve that plan.  Program must submit any building permits as required by Stamford building inspector, if applicable.
•	Room # 4.  The bedframe is broken.

Section 17a-145-Lavatory facilities.
Evidence: The shower stall (hygiene bathroom) is not used because the residents complain the water pressure is too low to shower.

Section 17a-145-75.  Health and medical treatment.
Evidence:  No evidence of RN working on site or visiting the building for Stamford and Fairfield Group Homes. There have been 13 admissions since 10/1/24 for Stamford.    Mental Health Technicians are present during some virtual assessments if an LPN is not on duty.  There have been several incidents of residents being restrained, but no RN came on site to provide a medical review of youth.

Section 17a-145-76. Kitchen, equipment, food -handling.
Evidence:
•	The façade of the cabinets in the kitchen are in poor condition due to wear and tear. The carousel in the kitchen next to the stove is broken and needs to be repaired.
•	The kitchen stove is missing a protective cover which is used to cover the gas pipe to prevent someone from accidently kicking the pipe.
•	The refrigerator handle is broken and one of the door shelves is broken.
•	The freezer handle is broken, and staff report the seal is broken to. It is not being used.

Errolee Miller, RN BSN MSN conducted an unannounced visit to program 11/8//24.
Section 17 a-145-93. Medical, dental, and nursing care - Health Care Standards of Children and Youth in Care and DPH RN Scope of practice and CT State Law.
Evidence:
During an unannounced visit to program on 11/8/24, interview with youths and staff and review of RN visit record identified the following violation:
Violations
Facility failed to provide an ongoing and consistent RN coverage to perform in person assessments or evaluation of youths, supervision of LPNs and oversight of medication certified staff since August 2024. It was noted that RN was providing these duties remotely which was not within the jurisdiction of the DCF Regulation or State law

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

Thomas S. Cuchara                                   12/18/2024
Regulatory Consultant                                   Date

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

description: a)

regulation: 12 ratio on all three shifts.

description: D

description: Section 17a-145-75.

area_type:
Health and medical treatment.
Evidence


summary: Visit conducted on _____9/24/24__________. Visit covered 8 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 / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       9:45am to 12pm ___                 DATE: _____9/24/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Assistant Program Director
	Education Liaison

List of Areas / Topics covered during visit:
•	LBC 12. Census is 5.
•	Met with Assistant Program Director and Educational Liaison who is also Interning at the program. Program Director returned from maternity leave.
•	Two Exceptional Circumstance reports received from the program.
•	Program's long time Medical Director resigned, and a new Medical Director hired, Richard Granese, from CA.
•	Program was quiet and youth were in their respective groups for school and recreation activities.
•	Controlled medications were counted.
•	Physical plant walk-through. No concerns.

Section 17a-145-74. Lavatory facilities.  Completed
Upstairs bathroom shower is broken.  It should be repaired.

Areas of regulatory non-compliance identified during this visit:
      No Regulatory Compliance Plan 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,                                    9/26/24
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan required.


summary: Visit conducted on _____6/13/24__________. Visit covered 9 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       10am to 12pm ___                 DATE: _____6/13/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title

	Assistant Program Director

List of Areas / Topics covered during visit:
•	LBC 12. Census is 11.
•	Assistant Program Director remains in this position until Program Director returns which is expected August.
•	Program is looking to hire 1 senior therapist and one Milieu staff.  At the time of the visit, 2 current clinicians see four residents and the program utilizes a clinician from the Southport GH and Assistant Program Director see the remaining two clients.
•	The program is also looking to hire a new RN following the departure of the previous RN.  Maria Torres is the Director of RN's for the group homes and providing RN coverage until a full time nurse is hired.  Assessments at time of admission are covered by the LPNs and reviewed by RN.
•	Program was quiet and youth were in their respective groups for school and recreation activities.
•	Program experienced two incidents that were followed up by licensing.  Program adjustments and policy and procedures were reviewed and revised and updated.
•	Program reports the cleaning service had been discontinued and staff were performing some functions.  It recently has started up again.
•	Physical plant walk-through. See below.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-74. Lavatory facilities.
Upstairs bathroom shower is broken.  It should be repaired.

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

Thomas S. Cuchara,                                    6/28/24
Regulatory Consultant                                   Date

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


summary: Visit conducted on _____2/21/24__________. Visit covered 8 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       10am to 12pm ___                 DATE: _____2/21/24__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Senior Therapist
	Assistant Program Director

List of Areas / Topics covered during visit:
•	LBC 12. Census is 8.  Census is capped at 8 in response to several vacant positions: Program Director, RN, 2 Clinicians.
•	Program Director position will be filled internally by the end of the month. The new program director will be available to see clients to help until all clinical staff are hired and trained.  All other positions are full currently.
•	Program is looking to hire 2 therapists.  The senior therapist will be leaving at the end of the month.
•	The program is also looking to hire a new RN following the departure of the previous RN.  Currently, the CT Director of RN's is splitting her time between Stamford and Fairfield GHs.   Shifts continue to be covered with LPNs and Medication Certified staff.
•	Program was quiet and youth were in their respective groups for school and recreation activities.
•	One youth seen isolating but clinician and Assistant Program Director are watching carefully and working with the medical director for guidance.
•	Physical plant walk-through. No concerns.

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,                                    2/27/24
Regulatory Consultant                                   Date

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

description: No SDP.


areas_topics_covered: LBC 12. Census is 8. Census is capped at 8 in response to several vacant positions: Program Director, RN, 2 Clinicians.

areas_topics_covered: Program Director position will be filled internally by the end of the month. The new program director will be available to see clients to help until all clinical staff are hired and trained. All other positions are full currently.

areas_topics_covered: Program is looking to hire 2 therapists. The senior therapist will be leaving at the end of the month.

areas_topics_covered: The program is also looking to hire a new RN following the departure of the previous RN. Currently, the CT Director of RN's is splitting her time between Stamford and Fairfield GHs. Shifts continue to be covered with LPNs and Medication Certified staff.

areas_topics_covered: Program was quiet and youth were in their respective groups for school and recreation activities.

areas_topics_covered: One youth seen isolating but clinician and Assistant Program Director are watching carefully and working with the medical director for guidance.

corrective_actions: 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, 2/27/24 Regulatory Consultant Date A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

description: No SDP.

facility_name: ____Discovery Practice Management / Stamford __________

personnel:
Senior Therapist
Assistant Program Director


summary: Visit conducted on _____12/15/23__________. Visit covered 10 main areas/topics. Found 1 compliance issues. Implemented 2 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       9:30am  to 11:15am___                 DATE: _____12/15/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Territory Operations Manager

  List of Areas / Topics covered during visit:
•	Census is 11.  LBC 12.  All female.
•	Program Director and milieu tech no longer work at the facility since 11/15/23.
•	Territory Operations Manager, VP of Eastern Region and Milieu Manager provide supervision and administrative support to staff throughout the week.  Administrative staff are on call on Sunday. Recommend a manager work on Sunday.
•	Program is in process of on-boarding new staff. Program reported all staff have been CPI trained and or refresher completed as well as CPR certified.
•	Residents observed participating with staff in a group.
•	Spoke with residents about their treatment, food, etc. in program; all had positive things to say.
•	Physical plant inspection of the Group Home.  No concern.
•	Discussed staffing of shifts and hiring status. Program is in process of interviewing for the Program Director position yesterday and two scheduled next week.
•	Reviewed and discussed the Policy and Procedure for Client Rights.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-76. Kitchen, equipment, food-handling.
Refrigerator part was back ordered and recently arrive. Program reports the handyman will fix it.  Completed.

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,                                    11/22/23
Regulatory Consultant                                   Date

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

description: No SDP.


summary: Visit conducted on _____9/19/23__________. Visit covered 7 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       9:30am  to 11am___                 DATE: _____9/19/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Milieu Manager
	Program Director
	RN
	Quality Management Coordinator

List of Areas / Topics covered during visit:
•	Census is 7.  LBC 12.  Five females and two males.
•	Residents observed participating with staff in a group.
•	Physical plant inspection of the Group Home. See below.
•	Discussed the programing challenges and resident's treatment and compliance.
•	One case reviewed and found no concerns.
•	Discussed staffing of shifts.
•	Reviewed Medication Administration with RN.  No concerns.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-76. Kitchen, equipment, food-handling.
Refrigerator part was back ordered and recently arrive. Program reports the handyman will fix it.

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,                                    11/22/23
Regulatory Consultant                                   Date

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

description: 76. Kitchen, equipment, food


summary: Visit conducted on _____6/8/23__________. Visit covered 5 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: ____Discovery Practice Management / Stamford __________

TIME OF VISIT (FROM - TO):       8:40am to 11:15am___                 DATE: _____6/8/23__________

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Milieu Manager
	Tech 4

List of Areas / Topics covered during visit:
•	Census is 12.  LBC 12.  Eleven females and one male.
•	Physical plant inspection of the Group Home. See below.
•	Discussed the programing challenges and resident's treatment and compliance.
•	One case reviewed and found no concerns.
•	Discussed staffing of shifts. No vacancies.

Corrective Actions implemented as a result of previous visit:
NO SDP from last visit.

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-76. Kitchen, equipment, food-handling.
Items were identified in the kitchen that need to be addressed.

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,                                    8/8/23
Regulatory Consultant                                   Date

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

description: 76. Kitchen, equipment, food

personnel:
Milieu Manager
Tech 4