summary: Visit conducted on 10-26-22. Found 1 compliance issues. Implemented 1 corrective actions.

raw_content:
Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Woodbury Washington Rd. Program

 TIME OF VISIT (FROM - TO):       1:00p-3:30p             DATE: 10-26-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Director of Operations
Clinical Director
Clients

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the physical plant, as well as obtain an update on the program since the relicensing inspection conducted in July 2022.
Discussion included:
•	Census = 7 males. The program is full.
•	Staffing: Staff to client ratios, staffing schedule, staffing vacancies (none), staff supervision procedures including bed checks, staff stations on the overnight shift, camera monitoring, nursing coverage.
•	Program: The program changed the gender served from females to males on 8-1-22 and an amended license was issued on that date. Discussed the resident daily schedule/routine, which involves attending meals, academics, group therapy and recreation activities with male residents in the other program on the Turnbridge Woodbury campus. Discussed client incidents with program management staff since the last Licensing visit which included two incidents of EMS/police involvement resulting in evaluation at a hospital. Recreation schedules for August through October were reviewed. Client interviews were conducted.
•	Food Services: Food storage was discussed. A 6-week menu cycle was reviewed. Discussion on menu approval process. Client interviews included discussion of food served. Discussed cleaning procedures for the refrigerator/freezer, as well as an unused refrigerator stored in the basement.
•	Physical plant tour: All areas of the Washington Road home appeared clean, organized, attractive and decorated for the season. Discussed enhancing infection control procedures in shared bathrooms. Discussion on outdoor fire pit. Breakaway closet rods are scheduled for installation. Discussion on possible installation of handrail at outdoor stone steps. Discussion on dining table seating and basement storage. Livingroom rug and coffee table have been replaced since last Licensing visit.

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

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

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

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


state: CT

raw_content:
July 25, 2022

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

Re: Turnbridge Washington Rd, Woodbury Girls group home
License #: CCF/GH #170
Regulatory Consultants: Kathleen Forsythe & Terri Bohara

Dear Dr. Cutter,

On July 19-20, 2022, a biennial re-licensing inspection was conducted for the Turnbridge girls group home, located at 760 Washington Rd., Woodbury, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124.

Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC on 6-28-22 to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A copy of the nursing review site visit summary report is included with this report.

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

The areas of regulatory noncompliance are as follows:

17a-145-64	Personnel Policies and Procedures.
A review of personnel files identified the following deficiencies:
•	Five (5) files did not contain evidence that employee received a physical examination immediately prior to assuming duties (TC, JD, JF, CF, TF).
•	Evidence of current CPR training was missing in one file (TF).

17a-145-66	Health, Sanitation, Fire Safety, and Zoning Approval.
Evidence of a local health inspection report for the license renewal was not provided with relicensing application materials.

17a-145-67	Water Supply. Sewage and Garbage Facilities.
Evidence of a current well water inspection report indicating the water is safe was not provided with relicensing application materials.

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.              17a-6(g)-15(a-g) DCF Medication Administration.
D) Based on a DCF nursing review, it was determined that:
o	the facility failed to provide quarterly training to all medication certified staff.
O	the facility failed to provide annual skills checks for two medication certified staff members (JB, SA).
F) Medication cabinets were found to contain internal and external medications stored together rather than separately.

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

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

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

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

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

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

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

Sincerely,

Kathleen Forsythe
_________________________
Kathleen Forsythe, LCSW
Regulatory Consultant

Cc: Executive Vice President|

report_type: unstructured


facility_name: Boys & Girls Village / STAR/ CCF#

summary: Visit conducted on 6/26/2025. 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: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __11am pm to 2pm___    DATE: 6/26/2025

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director

List of Areas / Topics covered during visit:

•	Census is 4. LBC has changed from 6 to 5 this quarter and a new amended license created.
•	At the time of the visit, 3 youth were in the building, and one was out with staff. Program was quiet.
•	Program has two 17-year-old and two 16 year old males.  One male will turn 18 by August and expected to be discharged to the MOP program.
•	Program has no vacant positions. All staff are TCI and CPR certified, and most staff are medication certified.
•	Program has a 2nd shift supervisor that covers during the week and weekend.
•	Program is experiencing numerous AWOLS and youth smoking marijuana. Room checks, and checks prior to entering building used to mitigate the behaviors.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:

17a-145-73. Sleeping accommodations.
The bedroom window frame and glass were found to be broken beyond repair and should be replaced due to two youth horseplaying. At the time of the visit agency maintenance had already boarded the window with plywood for safety.  Residents are not able to sleep in this room until the window is replaced.  Program is exploring using the window from the staff office as a replacement.

Broken glass was found outside and below the broken window that was not picked up.

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                           ___6/26/25_______
Regulatory Consultant                                   Date

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

type: general

facility_name: Boys and Girls Village / STAR


summary: Visit conducted on 5/20/2025. Visit covered 10 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):       __3:45pm to 6pm___    DATE: 5/20/2025

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Coordinator
	RN

List of Areas / Topics covered during visit:

•	Census is 5. LBC 6.
•	At the time of the visit, 3 youth were in the building. Fourth youth was outside playing basketball.  Youth appeared in good spirits and were getting snacks.
•	One resident stated he liked it at the program and gave it a "FIVE OUT of FIVE STAR RATING".
•	At the time of licensing visit the building was in good condition. No concern.
•	Met with RN who was at the program after 4pm.
•	Program has 5 medication certified staff.  All three shifts are covered. One staff member is med certified through another CT Agency and in the process of getting approval.
•	There is one 2nd shift vacancy.  Program is in process of interviewing 2 potential employees.  Vacant position filled with per diem staff until one is hired. First and third shifts are fully staffed.
•	AWOLs continue to be a choice of youth.  The age population is two 16 and three 17 yr olds.  All staff continue to address the AWOL via individually, and in group, but their multiple placement histories / life experience make it challenging. It is stated some youth have to wait long periods for placement; consequently, their ability to be focused on their future is severely compromised and they lose hope.
•	During the visit, a FFT foster parent dropped off cloths for one youth.  Staff were observed checking his belongings and found numerous bongs, vape pens, etc., which they promptly confiscated.
•	Safety: Staff do request that youth, upon enter building, are wanded for contraband.  Last quarter, staff found a 'magazine' filled with bullets that belonged to a handgun a youth attempted to bring into the building and another time about a dozen lose bullets were found in the dryer.

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                           ___5/27/25_______
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:
Program Director
Program Coordinator
RN


summary: Visit conducted on 3/27/2025. Visit covered 8 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __2pm to 4pm___    DATE: 3/27/2025

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Coordinator
	Clinician

List of Areas / Topics covered during visit:

•	Census is 5. LBC 6.
•	At the time of the visit, 4 youth were in the building. Youth appeared in good spirits and were getting snacks.
•	At the time of licensing visit the building was in good condition. No concern.
•	Medication, ie., controlled meds were reviewed and count correct.  Oswaldo is medication certified and will administer medication if need be.
•	They have one third shift staff member that is medication certified who works four days.  Oswaldo and another med certified staff provide additional coverage.
•	There is one vacant position on 2nd shift.
•	Numerous AWOLs occurred this month, most due to weather and placement issues such as not knowing where they will go that manifest as AWOLs. Youth that go AWOL return on building in a short period of time, however youth bring back vape pens and lighters that they stash in a secret location but attempt to bring back onto the unit.  Most of the time staff can confiscate the vape pens prior to entering the building. Program meets with youth about the dangers of vaping, etc.
•	Two youth are soon to turn 18.

Corrective Actions implemented as a result of previous visit:
   17a-145-75. Health and medical treatment.  Completed.
Evidence: Youth did not receive medication at the prescribed time, resulting in five separate medication errors. The program had assigned medication certified staff to arrive at the program to administer medication to youth, but the staff called out and there were no other staff available.  Program reports it is making efforts to train all staff in Medication Administration for all three shift to avoid similar experiences. So far two staff have been trained.  Please provide a plan to ensure all residents receive the medications on time as prescribed by the MD.

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

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                           ___3/28/25_______
Regulatory Consultant                                   Date

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


summary: Visit conducted on 12/12/24. 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: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __1pm to 3pm____    DATE: 12/12/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director

List of Areas / Topics covered during visit:

•	Census is 5. LBC 6.
•	At the time of the visit all 4 youth were in the building. Youth appeared on edge due to police presence, but cooperated with staff.
•	At the time of licensing visit, the Bridgeport police and Ambulance were at the building in response to a dysregulated youth.  PD reported youth was sent to the hospital for a psychiatric evaluation. Youth is said to have threatened to shoot up the facility and targeted one youth.  By history, this youth has the potential means to follow up on threats since he is able to contact peers outside the program.  To program staff the youth's threats are considered credible.  Threats to bodily harm and targeting a youth concerned the staff and residents living in the building had increased and become more violent. Program took measures to ensure staff and resident safety by requesting extra police presence, groups, staying away from windows, etc.
•	Five med errors recorded this quarter due to no medication certified staff.  Program had a plan but the plan went awry due to no staff follow up. Program reports two staff are medication certified.  The goal of the program is to have at least 10 staff med cert trained.
•	Program lost the part-time RN, but recently hired a new RN who will begin 12/6/24.
•	Numerous Exceptional Circumstance reports recorded this quarter due to AWOL and property destruction mainly from one youth who is now in the hospital.

Corrective Actions implemented as a result of previous visit:
   No Regulatory Compliance Plan from last visit.

Areas of regulatory non-compliance identified during this visit:
17a-145-75. Health and medical treatment.
Evidence: Youth did not receive medication at the prescribed time, resulting in five separate medication errors. The program had assigned medication certified staff to arrive at the program to administer medication to youth, but the staff called out and there were no other staff available.  Program reports it is making efforts to train all staff in Medication Administration for all three shift to avoid similar experiences. So far two staff have been trained.  Please provide a plan to ensure all residents receive the medications on time as prescribed by the MD.

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                           ___12/27/24_______
Regulatory Consultant                                   Date

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

area_type:
Health and medical treatment.
Evidence


summary: Visit conducted on 7/9/24. 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: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __9:45am to 12:10pm____    DATE: 7/9/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Program Coordinator

List of Areas / Topics covered during visit:

•	Census is 3. LBC 6.
•	At the time of the visit all 3 youth were downstairs eating with staff.  One youth became upset and walked outside.  Staff quickly intervened and quietly returned youth to the building.  Upon leaving, the youth was clearly in a good frame of mind, interacting with staff and peers.
•	One youth is enrolled in summer school and the other completed summer school last week.  The third was admitted last month and under house arrest.  The program is actively working with DCF to enroll him in a school program.
•	Program continues to address challenging behaviors.
•	Followed up on significant event reports.
•	Discussed staffing of shifts. There are two open FTE positions.  Program plans to hire from the list of per diem staff.
•	Reviewed RN admission assessment to ensure it was completed within the 72 hour time fame.  No concern.
•	Program lost a well liked and respected staff member, who died suddenly, last week.  He was beloved by peers and youth.  Staff continue to process his loss through individual therapy and groups.  The residents on their own initiative built a small remembrance table for him.

Corrective Actions implemented as a result of previous visit:
   No Regulatory Compliance Plan from last visit.

Areas of regulatory non-compliance identified during this visit:
No Regulatory Compliance Plan.

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                           ___7/10/24_______
Regulatory Consultant                                   Date

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

description: No Regulatory Compliance Plan.

personnel:
Program Director
Program Coordinator


raw_content:
Kim Shaunesey, PhD.							5/6/2024
Executive Director
Boys & Girls Village Inc.
528 Wheelers Farm Rd.
Milford, CT 06461

Re: Licensing Inspection for CCF BGV STAR Home
       Regular License #CCF 172
       Regulatory Consultants: Tom Cuchara & Jim Funaro

Dear Dr. Shaunesey,

On 2/29/24, 4/16/24, 4/17/24, 4/23/24 a biennial re-licensing inspection was conducted at 222 Bennett Street, Bridgeport, CT.  This inspection was conducted to determine the compliance of this agency with the Licensure of the Operation of Child-Caring Agencies and Facilities 17a-145-48 through 17a-145-98. 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 Regulation 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 Regulation Compliance Plan as well.  Also included in the report are recommendations.

Section 17a-145-73. Sleeping accommodations.
Evidence: During the inspection, one wall in Room #3 was damaged, exposing sheetrock, due to youth picking at the paint.  In addition, the wall is found to be in poor condition.

DCF Reg: 17a-145-75 (f) and 17a- 6(g)- 16(d). Provide and maintain proper, safe storage for all medications according to current drug control and pharmacy regulations as outlined in the DCF Medication administration program.
Evidence:  Observation of medication room and contents identified that Youth #1's medication was discontinued in February, with the last dose administered on 02/28/2024. These medications were not removed from the current medication/s being administered (medications included Seroquel and Depakote).

•	Per regulation, only medication that is prescribed and labeled may be accessible to DCF Med Cert staff. These medications must be separated from the routine daily supply and placed in a secure storage for prompt destruction.
•	The facility failed to meet this requirement when discontinued medication was found among current medications.

DCF 17a-145-93= Medical, Dental, and Nursing Care; a nursing assessment of the child needs to be done as soon as possible but no later than 72 hours after admission to program.
•	Each youth admitted to Program shall have a Nursing Care Plan that is based on the assessment data obtained during the admission process and incorporated into the treatment plan and reviewed quarterly.
•	Nurse should document all nursing interventions and care provided for each client/youth.
•	The Nurse is responsible to complete DCF- 2270 Congregate Care Quarterly Nursing Assessment, every ninety days from the date of admission, and that it is sent to the Youth's Social Worker and Regional Resource Group Nurse.
•	Program should have a DCF Drug Administration handbook available as reference to licensed and Med Cert staff.

Evidence: Facility failed to meet this requirement when two of three youths at facility Nursing assessment was not completed until 5 days after admission.
•	No Nursing Care Plan or Nursing notes noted in clinical record.
•	No DCF-2270 Submitted for Youth #1 that had been admitted to facility since 06/2023.
•	No DCF Drug Handbook in Medication room, staff identified they were not familiar.

Section 17a-145-96. Discharge of child.
Evidence: One record had no evidence who the youth was discharged to.

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

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

Sincerely,

Thomas S. Cuchara
Regulatory Consultant

Copy: file|


summary: Visit conducted on 1/30/24. 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: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __12:45pm to 3:30pm____    DATE: 1/30/24

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Youth Mentor

List of Areas / Topics covered during visit:

•	Census is 6. LBC 6.
•	At the time of the visit all 4 youth were in the building 2 in school.
•	4 youth home from school.  Program communicates weekly with DCF to schedule and secure transportation.  2 youth were home recuperating from being sick.
•	Program continues to address challenging behaviors such as AWOL through keeping youth busy, when home and frequent walks around the block with staff.
•	Physical plant inspection was conducted.  No concerns
•	Followed up on significant event reports.
•	Discussed staffing of shifts. No vacancies.  Full time 2nd shift supervisor is hired and working.  This has added relief for Youth Mentors.
•	Reviewed and found in compliance medication, specifically, controlled meds for one youth. Count is correct.   Staff report there is no second shift Med. Cert. staff, but medication is administered by per diem staff and part time RN. Discussed proper documentation and sign off.
•	One N/A report 1/11/24.  One SIU report 1/11/24

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

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                           ___2/2/24_______
Regulatory Consultant                                   Date

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

description: No SDP

personnel:
Program Director
Youth Mentor


summary: Visit conducted on 12/04/23. 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):       __9:20am 1:15pm__________    DATE: 12/04/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Clinician
	Program Coordinator

List of Areas / Topics covered during visit:

•	Census is 6. LBC 6.
•	At the time of the visit all 4 youth were in school.
•	Two youth were home and described living here as positive. They had no complaints, other than wanting to return home.
•	Physical plant inspection was conducted.  No concerns
•	Discussed the programing, length of stay and impact on residents and resident safety. Residents are very challenging. They AWOL, threaten staff and peers.
•	Followed up on significant event reports.
•	Discussed staffing of shifts. No vacancies.  Program intends to hire a 2nd shift supervisor for the weekends.

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

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                           ___12/13/23_______
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 9/18/23. Visit covered 6 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):       __9:10am 10:30am__________    DATE: 9/18/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director

List of Areas / Topics covered during visit:

•	Census is 6. LBC 6.
•	At the time of the visit all youth were in school.
•	Physical plant inspection was conducted.  See below.
•	Discussed the programing, resident safety.
•	Followed up on significant event reports.
•	Discussed staffing of shifts.

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

Areas of regulatory non-compliance identified during this visit:
Section 17a-145-73. Sleeping accommodations.
Evidence of water damage in ceiling tile found in bedroom #2.

Section 17a-145-74. Lavatory facilities. Shower on second floor has mold in the soap holder.

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                           ___9/22/23_______
Regulatory Consultant                                   Date

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


summary: Visit conducted on 4/27/23. Visit covered 6 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __10am__________               DATE: 4/27/23

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	Program Director
	Milieu Staff

List of Areas / Topics covered during visit:

•	Census is 4. LBC 6.
•	At the time of the visit one youth in the program, but is a new admission.
•	Physical plant inspection was conducted and in compliance.
•	Discussed the programing, resident safety, juggling room challenges.
•	Discussed staffing of shifts.
•	Fire drills reviewed for the 1st quarter for 2023.  No concern.

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

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.

Thomas S. Cuchara                           ___5/4/23_______
Regulatory Consultant                                   Date

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

personnel:
Program Director
Milieu Staff


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

personnel:
OT	Program Director
WS	Milieu Staff


summary: Visit conducted on ___10/25/22____. Visit covered 4 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __10am _______________________               DATE: ___10/25/22____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
OT	Program Director
DV	Vice President of Residential Services
DB	Program Coordinator
LP	Clinical Coordinator
WS	Youth Mentor

List of Areas / Topics covered during visit:
The STAR program is currently under a 2nd Provisional license.  The license expires 10/28/22.  The LBC is 4 with age range 14 to 18.  The STAR accepts Boys.
•	At the time of the visit the census is 2 who were in school at the start of the visit.  One youth returned from school.  He stated he likes it here and is treated well.
•	Physical plant has no concerns
•	Discussed the programing, supervision of residents, resident safety, etc.
•	Medication room was reviewed, and citation listed below.

Corrective Actions implemented as a result of previous visit:
No corrective action required from last visit.

Areas of regulatory non-compliance identified during this visit:

Medication Guidelines:
The non-controlled mediation key was found in the cabinet lock where non-controlled medication is stored. Consequently, the key was not in possession of the staff member assigned to administer medication, per Medication Guidelines training. The mediation room is accessible to all medication certified staff or others with access via the key fob.  In addition, there is no evidence whereby staff document a key exchange 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                           ___10/28/2022_______
Regulatory Consultant                                   Date

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

area_type: Medication Guidelines


summary: Visit conducted on ___7/22/22____. Visit covered 4 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / STAR

 TIME OF VISIT (FROM - TO):       __10am_______________________               DATE: ___7/22/22____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
OT	Program Director
LP	Clinical Coordinator
BK	Family Support Worker
DJ	Program Coordinator

List of Areas / Topics covered during visit:
This is a STAR program is under its 1st Provisional license.  The license will expire 8/28/2022.  The LBC is 4 with age range 14 to 18.  The STAR accepts Boys.
•	At the time of the visit there was no youth in the program.
•	Physical plant inspection was completed and in compliance.
•	Discussed the programing, resident safety (rooms and fire drills), food storage, etc.
•	Discussed staffing of shifts. Staff noted that they are in the process of hiring two staff.  Vacant positions are filled by per diem BGV staff.

Corrective Actions implemented as a result of previous visit:

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

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

Thomas S. Cuchara                           ___7/22/2022_______
Regulatory Consultant                                   Date

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


facility_name: Bridge Family Center

summary: Visit conducted on 7/22/25. Visit covered 7 main areas/topics. Found 2 compliance issues.

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

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

NAME OF FACILITY / PROGRAM: The Bridge Family Centers-Hastings House
TIME OF VISIT (FROM - TO):     10:40-11:45am              			DATE: 7/22/25
AGENCY PERSONNEL WHO PARTICIPATED: Program Director

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Status reports on residents and discharge planning
•	Staffing: Staff participating in Restorative Justice training on 7/22/25 (2-10pm)
•	Programming (Bridge Bucks, Allowance, level system)
•	AWOL reporting protocol reviewed
•	Summer Recreation
•	Physical Plant observed to be clean.

Milieu observation:
•	Staff/client interactions: There were three (3) youth home.  Two (2) were in the living room with staff, while one (1) was in his bedroom and was observed to have a cast on from sustaining a broken wrist and elbow from a fall during a recent AWOL.  Youth appeared comfortable in communicating needs with staff.  Staff was observed cooking breakfast for youth that woke up late and later staff took youth out swimming.
•	Two (2) youth were at work and one (1) youth was attending a camping excursion at the Wilderness School through DCF.

Corrective Actions implemented as a result of previous visit: - Not applicable.
Areas of regulatory non-compliance identified during this visit:
Section 17a-145-63. Chief administrative officer:
•	Outdoor deck is missing railing and steps are broken.  (Landlord has been contacted to repair and scheduled for 7/28/25)

Section 17a-145-73-Sleeping Accommodations:
•	Bedroom #4-window handle broken and window is inoperable and there are missing window screens.

Section 17a-145-76: Kitchens, equipment, food-handling:
•	Oven handle cracked.

Please submit a regulation compliance plan to address the above-mentioned areas of non-compliance within 30 days of receipt of this report.
Amita Patel, LMSW			Date: 8/4/25
Regulatory Consultant

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

Cc: Program Director
File|

description: Section 17a-145-76:


summary: Visit covered 6 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:  Hastings House/ Bridge Family Center

TIME OF VISIT 9:30-11:30     				 				DATE:  6/27/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Director of Residential Services
Program Director

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Status reports on residents and discharge planning
•	Staffing: Program director started on 6/16/25 and second shift supervisor 6/17/25
•	Programming (Bridge Bucks, Allowance, level system)
•	Summer Recreation
•	Physical Plant observed to be clean.

Milieu observation:
•	Staff/client interactions:  Two (2) youth were in the living room with staff watching tv together.  One (1) youth was sleeping due to his arrival to the program the prior night before.  Another youth was walking around the house during the visit and engaged freely with staff and appeared to try to get the PD's attention.

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63. Chief administrative officer:
•	Outdoor deck is missing railing and steps are broken.  (Landlord has been contacted to repair)

Section 17a-145-73-Sleeping Accommodations:
•	Bedroom #2 -Broken Trim is cracked/broken
•	Bedroom #3, 4,5 -Window screens missing and/or broken
•	Bedroom #1- has paint on the floor and on the desk

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens
•	First Floor Bathroom screen missing
•	First floor bathroom missing radiator cover and radiator is rusting

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

•	Oven handle is cracked

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

Amita Patel										Date:     7/8/25
Regulatory Consultant

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

facility_name: Hastings House/ Bridge Family Center


summary: Visit covered 5 main areas/topics. Found 7 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:  Hastings House/ Bridge Family Center

TIME OF VISIT 12:15pm-12:50pm     				 				DATE:  5/30/25

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Clinical Director of Residential Services

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Status reports on residents and recently discharged youth
•	Programming (Bridge Bucks, Allowance, level system)
•	Physical Plant observed to be clean.  However, there is "damp" odor in the basement.  There were two (2)  de-humidifiers that both needed to be emptied.

Milieu observation:
•	Staff/client interactions:  One (1) youth arrived back to the program from a medical appointment. He reported he was doing well and had no concerns at the program.

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73-Sleeping Accommodations:
•	Bedroom #2 -Broken Trim is cracked/broken
•	Bedroom #2, 3, 4, 6-Window screens missing and/or broken

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens
•	First Floor Bathroom screen missing
•	Second Floor doorknob missing (work order submitted)

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

Amita Patel										Date:     6/3/25
Regulatory Consultant

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

description: Sleeping Accommodations:

description: Bedroom #2

description: Broken Trim is cracked/broken

description: Bedroom #2, 3, 4, 6

description: First Floor Bathroom screen missing


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

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:  Hastings House/ Bridge Family Center

TIME OF VISIT (1-3pm):     				 			DATE:  4/21/25 (Quarterly Visit)  												5/6/25 (Personnel File Review)

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Director Residential Services
DCF Program Supervisor

List of Areas / Topics covered during visit:
•	Census = 5 male; LBC= 6
•	Status reports on residents
•	Staffing vacancies:  Program Director, 2nd shift supervisor, two (2) full time (2nd shift & 3rd shift)
(Current vacancies are being covered by temporary staffing agency, per diem and Hastings staff working overtime).
•	Medication Administration (currently only two (2) staff are covering for all shifts
•	Recreation (Movies, Trampoline Park, Go-Karting, Hiking, Basketball Hall of Fam, Easter egg hunt)
•	Programming (Bridge Bucks, Allowance, level system)
•	New on call procedure/back up
•	Director of Residential Supervisor

Milieu observation:
•	Staff/client interactions:  One (1) youth arrived back to the program from a medical appointment. He reported he was doing well and had no concerns at the program.

Physical Plant observed to be clean

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73-Sleeping Accommodations:
•	Bedroom #1-Broken Bedroom Blinds are broken
•	Bedroom #2 -Broken Trim is cracked/broken
•	Bedroom #2, 3, 4, 6-Window screens missing and/or broken

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens
•	First Floor Bathroom screen missing

17a-151    Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	The results of a national criminal history background check are missing in five (5) files (CD, TE, AV, NS, LS)

•	Out of state background not completed for CPS in NY CPS for one (1) employee (NS)

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

Amita Patel											Date:     6/5/25
Regulatory Consultant

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


summary: Visit covered 5 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:  Hastings House/ Bridge Family Center

TIME OF VISIT (12:30-1:30pm):     				 				DATE:  12/12/24

 AGENCY PERSONNEL WHO PARTICIPATED:
Program Clinician, Staff

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Status reports on residents
•	Staffing vacancies :  The exact number of vacancies is unknown as the PD was unavailable.  Current vacancies are being covered by temporary staffing agency, per diem and Hastings staff working overtime.
•	Discharge planning and clinical programming reviewed.
•	Recreation

Milieu observation:
•	Staff/client interactions:  One (1) youth arrived home from school. Staff offered him lunch and after eating youth came up to his bedroom while t/w was touring.  He reported no concerns in the program.

Physical Plant observed to be clean

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73-Sleeping Accommodations:

•	Several bedrooms (2, 3, 4, 6) had some evidence of wear and graffiti.  Bedroom #3 had a broken desk drawer.

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

Amita Patel			Date:     12/18/24
Regulatory Consultant

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

description: Bedroom #3 had a broken desk drawer.


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:  Hastings House/ Bridge Family Center

TIME OF VISIT (1-3:30pm):     				 				DATE:  7/24/24

 AGENCY PERSONNEL WHO PARTICIPATED:
Program Manager

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Status reports on residents
•	Staffing vacancies :  1st shift: One (1) full time &  two (2) part time direct care workers,
2nd shift:  three (3) full time direct care workers, one (1) full time second shift supervisor.
3rd shift:  one (1) full time direct care worker.  Current vacancies are being covered by temporary staffing agency, per diem and Hastings staff working overtime.
•	Discharge planning
•	Recreation
•	Increase Significant Events reviewed related to one(1) youth and new policy with EMS having to medically clear youth that appear or are under the influence of alcohol/drugs.

Milieu observation:
•	Staff/client interactions (staff observed to be playing cards with one(1) youth in the dining room. Two (2) youth at camp, two (2) at summer school, one (1) youth is working and one (1) AWOL.

Physical Plant observed to be clean

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73-Sleeping Accommodations:

•	Damaged blinds bedroom #6-work order submitted.

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

•	Bathroom vanity top cracked on 1st floor-work order submitted

Section 17a-145-85- Housekeeping equipment and supplies:

•	Cleaning supplies were located under the bathroom vanity on the 1st floor.

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

Amita Patel			Date:     8/1/24
Regulatory Consultant

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

description: Section 17a-145-74:


summary: Visit covered 7 main areas/topics. Found 10 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:  Hastings House/ Bridge Family Center

TIME OF VISIT (2:30pm-4pm):     				 				DATE:5/2/24

 AGENCY PERSONNEL WHO PARTICIPATED:
Assistant Clinical Director

List of Areas / Topics covered during visit:
•	Census = 6 male; LBC= 6
•	Status reports on residents
•	Staffing
•	Discharge planning
•	Recreation
•	Significant Events reviewed
•	New bedroom (heavy duty) furniture observed in bedrooms

Milieu observation:
•	Staff/client interactions (staff observed to be playing cards with youth outside on the deck)

Physical Plant observed to be clean

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-71. Living room, lounge:

•	Damaged blinds **work order submitted

Section 17a-145-73-Sleeping Accommodations:

•	Window screens-missing/broken or damaged window screen (Bedroom 1, 2,3,6)  **Work order submitted
•	Damaged Door (bedroom #1-closet)  **Work order submitted
•	Missing mattress Pad/cover (Bedroom #2)

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

Amita Patel			Date:     6/14/24
Regulatory Consultant

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

description: 71. Living room, lounge:

description: Damaged blinds

description: Window screens

description: Work order submitted

description: Damaged Door (bedroom #1

description: closet)

description: Work order submitted

description: Missing mattress Pad/cover (Bedroom #2)


summary: Visit covered 9 main areas/topics. Found 2 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:  Hastings House/ Bridge Family Center

TIME OF VISIT (130pm-4pm):     				 				DATE:2/15/24

 AGENCY PERSONNEL WHO PARTICIPATED:
Program Director
Assistant Clinical Director

List of Areas / Topics covered during visit:
•	Census = 5 male; LBC= 6
•	Status reports on residents
•	Staffing
•	Discharge planning
•	Recreation
•	Increase in Police Calls
•	Significant Events reviewed
•	New furniture observed in living room, dining room
•	New bedroom (heavy duty) furniture ordered

Milieu observation:
•	Staff/client interactions (1youth home, 3 youth in school and 1 youth AWOL)

Physical Plan observed to be clean

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73-Sleeping Accommodations:

•	Bedroom #6 broken furniture (armoire/dresser)

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

Amita Patel			Date:     4/5/24
Regulatory Consultant

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

description: Sleeping Accommodations:


summary: 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:  Hastings House/ Bridge Family Center

TIME OF VISIT (2-4pm):     				 				DATE:9/21/23

 AGENCY PERSONNEL WHO PARTICIPATED:
Program Director
Assistant Clinical Director

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

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

Physical Plant:
•	Oven-needs cleaning
•	Poor Air Quality in basement as it smells "damp"
•	Threshold to the basement needs to replaced as it presents as a trip/safety hazard
•	Both resident bathrooms need hand soap and paper towels or hand towel
•	Bathroom window screen needs to be replaced/repaired (1st floor)

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

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-71. Living Room, lounge
•	Basement Air Quality-smells damp
•	Basement Threshold needs to be replaced as it poses a tripping hazard

Section 17a-145-74:  Lavatory facilities:  Toilet articles and linens
•	Resident bathrooms (1st, 2nd floor) are missing hand towel or paper towels and hand soap.

Section 17a-145-76: Kitchens, equipment, food-handling:
•	Oven-inside needs to be cleaned.

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

Amita Patel			Date:     9/29/23
Regulatory Consultant

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

areas_topics_covered:
Census = 6 male; LBC= 6
Client Supervision
Frequency & Documentation
Status reports on residents
Staffing
Client Recreation
Discharge planning

description: Section 17a-145-76:


summary: Visit conducted on 5/10/23. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House

 TIME OF VISIT (FROM - TO):       __11am to 1pm______               DATE: 5/10/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director

List of Areas / Topics covered during visit:
Census is 6.  LBC 6.  6 males.
Physical plant inspection of the STAR. No concerns.
Discussed program issues and concerns.
Discussed staffing of shifts.
Medication: Controlled medication reviewed.  N/A

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

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

Please submit a 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.

 N/A

Thomas S. Cuchara                           ___5/15/23_______
Regulatory Consultant                                   Date

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

facility_name: _Bridge Family Center / Hastings House


summary: Visit conducted on 3/30/23. No compliance issues identified.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House

 TIME OF VISIT (FROM - TO):       __11am to 12:15pm__________               DATE: 3/30/23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Program Director
Program Coordinator

List of Areas / Topics covered during visit:
Census is 3.  LBC 6.  6 males.
Physical plant inspection of the Group Home. No concerns.
Discussed program issues and concerns.
Discussed staffing of shifts.
Medication: Controlled medication reviewed.  N/A

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

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

Please submit a 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. N/A

Thomas S. Cuchara                           ___3/31/23_______
Regulatory Consultant                                   Date

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


summary: Visit conducted on ___12/21/2022____. 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: _Bridge Family Center / Hastings House

 TIME OF VISIT (FROM - TO):       ___2pm_______________________               DATE: ___12/21/2022____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
SH	Program Director

List of Areas / Topics covered during visit:
•	Census is 5 and LBC 6.  6 males.  One youth is in detention.
•	Physical plant inspection of the Group Home.
•	Residents were at school.
•	Discussed staffing of shifts.
•	One case record reviewed and found in compliance.

Corrective Actions implemented as a result of previous visit:
17a-145-73. Sleeping accommodations.  Completed.
At the time of the visit Rooms 4 & 6 found the wood trim around the bedroom door is broken. A work order was put in for repair.  Licensing will follow up on next visit.

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

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                           ___2/3/23_______
Regulatory Consultant                                   Date

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

description: No SDP needed.


summary: Visit conducted on ___9/28/22____. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: _Bridge Family Center / Hastings House

 TIME OF VISIT (FROM - TO):       ___9am_______________________               DATE: ___9/28/22____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
SH	Program Director

List of Areas / Topics covered during visit:
•	Census is 3 and LBC 6.  6 males.
•	Physical plant inspection of the Group Home. Program Director reports a new dining room table and chairs were purchased.  New patio furniture for the deck and new dressers for bedrooms ordered.
•	Discussed the programing and resident's treatment and compliance.
•	Residents were at school.
•	Discussed staffing of shifts. Interim Clinical Coordinator used until a fulltime clinician is hired.  APRN hired to provide supervision for Medication Administration Program.
•	One case record reviewed and found in compliance.

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

Areas of regulatory non-compliance identified during this visit:
17a-145-73. Sleeping accommodations.
At the time of the visit Rooms 4 & 6 found the wood trim around the bedroom door is broken. A work order was put for repair.  Licensing will follow up on next 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                           ___11/10/2022_______
Regulatory Consultant                                   Date

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


summary: Visit conducted on ___6/7/22____. 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: _Bridge Family Center / Hastings House

 TIME OF VISIT (FROM - TO):       ___1pm_______________________               DATE: ___6/7/22____

 AGENCY PERSONNEL WHO PARTICIPATED:

Name	Job Title
SH	Program Director
MW	Clinical Coordinator

List of Areas / Topics covered during visit:
•	Census is 6 and LBC 6.  6 males.
•	Physical plant inspection of the Group Home.  No concerns.
•	Discussed the programing and resident's treatment and compliance. Program Director relayed there has been awols due to oppositional defiant behaviors. The program works with each resident individually to address their issues.  One resident who has struggled with ADL skills made significant changes for which he is very proud.
•	Residents were at school.
•	Discussed staffing of shifts. Clinical Coordinator announced their resignation, but will continue on parttime until a replacement is found.  The RN covering Hastings, Winifred and Harwinton resigned. The program will use the RN from Freymann House until a replacement is found.

Corrective Actions implemented as a result of previous visit:
Section 17a-145-73. Sleeping accommodations.   Completed.
One bedroom had evidence of broken blinds that covered his window.  A work order has been submitted.

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                           ___7/8/2022_______
Regulatory Consultant                                   Date

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

description: No SDP required.


summary: Visit conducted on 7/21/25. Visit covered 8 main areas/topics. Found 2 compliance issues.

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

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

NAME OF FACILITY / PROGRAM: The Bridge Family Centers-Winifred House
TIME OF VISIT (FROM - TO):     11:45am-12:30pm              			DATE: 7/21/25
AGENCY PERSONNEL WHO PARTICIPATED: Program Director
List of Areas / Topics covered during visit:
•	Census = 4; LBC= 4 (male)
•	Status reports on residents and discharge planning
•	Staff Trainings: Restorative Justice (RJ) training on 7/22/25 (2-10pm), School Refusal Training (7/23/25)
•	Programming (Bridge Bucks, Allowance, level system)
•	Summer Recreation-Lake Compounce, Top Golf, Back to School Barbeque being planned
•	Physical Plant observed to be clean.

Milieu observation:
•	Staff/client interactions: One (1) youth was home in his bedroom while three (3) youth were attending summer school.

Corrective Actions implemented as a result of previous visit: - Not applicable.
Areas of regulatory non-compliance identified during this visit:

Section 17a-145-73-Sleeping Accommodations:
•	Bedroom A- window not staying closed as the top half is sliding down.
•	Bedroom A-hole in wall behind door caused by doorknob.
•	All windowsills in the bedrooms have chipping paint.

Section 17a-145-76: Kitchens, equipment, food-handling:
•	Edge/Trim of kitchen counter missing needs to be addressed.
•	Partial Kitchen counter backsplash is missing exposing unfished wall with a hole in the wall.

Please submit a regulation compliance plan to address the above-mentioned areas of non-compliance within 30 days of receipt of this report.

Amita Patel, LMSW			Date: 8/4/25
Regulatory Consultant
A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM

Cc: Program Director
File|


summary: Visit covered 8 main areas/topics.

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

Field Visit Reporting Form

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

NAME OF FACILITY / Winifred House/The Bridge Family Center

TIME OF VISIT (FROM TO): 1:45-2:40pm   				DATE: 5/30/25

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Program Director
Program Clinician

List of Areas / Topics covered during visit:

•	Census = 5 male; LBC= 4
•	Status reports on residents
•	Staff/client interactions:  One (1) youth was home as he was newly placed.  Youth has just returned home from shopping trip with staff.  Another youth was in his bedroom located on the first floor.
•	Programming reported to be successful as most youth are working to earn Bridge Bucks, Allowance, stay on level to earn privileges)
•	Recreation (Talcott Mountain, Go-Karting, Dinner, Basketball at local parks)
•	Significant Events
•	Physical Plant observed to be clean and free from safety concerns

Areas of regulatory non-compliance identified during this visit:

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

Amita Patel			Date:6/3/25
Regulatory Consultant

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


summary: Visit covered 11 main areas/topics. Found 2 compliance issues.

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

Field Visit Reporting Form

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

NAME OF FACILITY / Winifred House/The Bridge Family Center

TIME OF VISIT (FROM TO): 10:50am-2pm
DATE: 4/25/25 (Quarterly Visit)
										          5/6/25 (Personnel File Review)

AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:  	Director of Residential Services
		Program Director
Program Clinician

List of Areas / Topics covered during visit:

•	Census = 5 male; LBC= 6
•	Status reports on residents
•	Staffing Vacancies: Two part-time weekend (1st shift, 3rd shift)
•	Staff/client interactions:  One (1) youth was home as he was newly placed.  Youth was observed playing basketball and sitting outside while supervised by staff and later youth was sitting on the deck talking on the phone.
•	Programming (Bridge Bucks, Allowance, level system, Staff appreciation/Recognition)
•	Record Review
•	Medication Administration
•	Recreation (Mystic, Hiking)
•	Community Meeting/Restorative Justice
•	Significant Events

Areas of regulatory non-compliance identified during this visit:

Section 17a-145-63:  Chief administrative officer:
•	The basement has a strong unpleasant odor.  The source of odor needs to be addressed.

Section 17a-145-63:  Chief administrative officer:
•	Bedroom B-Two (2) window screens are missing and need to be replaced

17a-151    Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	The results of a national criminal history background check are missing in four (4) files (CA, PD, HM, EM)

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

Amita Patel			Date:5/1/25
Regulatory Consultant

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

personnel:
Program Director
Program Clinician


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

Corporate Name: The Bridge Family Center	Program Name: Winifred House STTAR                   Date: 10/7/24
                                                                               Amended - 11/4/24
                                                                                Amended- 1/21/24

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

Area Needing Attention	The Bridge Plan of Correction	Completion Date	Title/Person Responsible to Monitor Plan
Section 17a-145-62. Chief administrative officer (Each facility shall provide the staff and complementary services to enhance the physical and emotional well-being and ensure the safety of the children.
a.	Submit a comprehensive plan outlining how staff are trained/re-trained in all policies and practices related to medication administration, to include all processes, supervision of staff, documentation, and other quality assurance measures to ensure the effective execution of the agency’s medication administration program.
aa. Submit a comprehensive plan outlining    efficient organization of medication distribution times that promotes the safety of youth in the program, ie dutch door, sliding window, etc.

 b. Submit a detailed plan outlining how                                                                            the outside condition of the home will be addressed, repaired, and maintained on a consistent basis.
•	Physical plant: broken patio chairs, broken patio umbrella, deck floorboard, broken grill, graffiti on the siding of the house.

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

Section 17a-6(g)-16(b) Facility is responsible for the provision of adequate back-up by licensed personnel to meet the needs of youth.
•	Submit a comprehensive plan outlining: 1. How drugs, medicines and medical instruments will be available to med certified staff for distribution to residents 2. How med certified staff will be trained & re-trained (also see above regulation Section 17a-145-62) 3. The oversight and supervision of med certified staff, 4. communication between staff and from staff to supervisors 5. Notification plan when med errors occur 6. Nursing responsibilities to ensure the effective oversight of the med admin program to include frequent education of med cert staff 7. Remedial consequences for staff that violate this plan.

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

•	On 9/4/24 & 9/5/24, AF missed four days of medication due to refills not replenished.
•	Between 9/6/24 – 9/9/24 youth (AF) missed his medication due to a compromised lock box for controlled medication. Also, on 9/8/24, there was no Med Certified staff to administer medications to two youth (AF, AG)
•	Staff failed to follow the agency's policy and procedures regarding notification in the event med certified staff is unavailable to administer medications. Staff also did not notify supervisors immediately regarding the compromised lock box.
•	On 9/25/24, DCF was notified that there was a medication administration error that occurred on 9/24/24, in which one youth (AG) was given two incorrect medications that were prescribed to youth (AF).
•	On 9/24/24, agency staff failed to notify other staff or their supervisor of the medication error.

•	Please provide a (internal to Winifred House) full med cert coverage schedule of all shifts, including the two staff that are waiting for their certificates, as of 1/31/25

•	On 12/22/24, DCF was notified that there was a medication administration error that occurred on 12/22/24, in which one youth (AG) was given the incorrect dosage of medication.
Section 17a-145-73 Sleeping Accommodations.
•	 Submit a detailed plan outlining how the conditions of the home will be addressed and maintained on a consistent basis.
•	Single bedroom- 1st floor bedroom-desk has graffiti/writing on it.  The curtains need to be replaced as they appear worn.
•	Double bedroom-2nd floor (right of bathroom)- bedroom was extremely unkempt with clothes, food/candy wrappers, broken fan, burn marks on desk chair, dirty bedsheets on one (1) bed, missing bedsheets and pillow protectors/pillowcases on two (2) beds.
•	Double bedroom-2nd floor (left of bathroom)-damaged walls (old repairs/patches to the wall need to be painted and a new hole in the walls needs to be repaired), missing electric switch plate cover, bedroom extremely unkempt with clothes, food/candy wrappers, burn marks on hardwood floor.

Section 17a-145-74 Lavatory facilities: Toilet articles and linens.
•	Submit a detailed plan outlining how the conditions of the home will be addressed and maintained on a consistent basis.
•	2nd floor bathroom- bathtub was extremely dirty, paper towels were missing, hand soap dispenser is broken and needs to be replaced, sink had hair and dried up toothpaste in it, the mirror was smeared with a white substance, and the electric outlet switch plate was missing.

Section 17a-145-76. Kitchens, equipment, food-handling.
•	Submit a detailed plan outlining how                                                                            the conditions of the home will be addressed and maintained on a consistent basis.
•	There was unwrapped food in both the refrigerator and the freezer in the kitchen.

Section 17a-145-77: Dining Areas and Supervision.
•	Submit a detailed plan outlining how the conditions of the home will be addressed and maintained on a consistent basis.
•	The dining room table has only five chairs (5) and the program's licensed bed capacity is 6.

a.	See attachment 1A Titled: Comprehensive Training and Retraining Plan for Medication Administration Policies and Practices

A dutch door will be installed to the staff office to promote a more organized medication pass within the program. The current door is metal framed so a new door and frame will be ordered and installed.

b.	The Program Director will maintain outside conditions of the home and repairs by submitting work orders daily. The Facilities Coordinator will remove larger debris items from the outside on a weekly basis.

Corrections – Patio furniture and broken grill were removed and disposed of. Graffiti on siding is being painted over. Deck floorboards evaluated for needed repair. Contractor visited on 10/10/24- Repaired.

1.	See attachment 1B Titled: Comprehensive Plan outline for Medication Distribution and Oversight

2.	In June a new Employee pathway was created to improve tracking employee 90-day training to include medication administration. Upon hire, staff are recommended to complete medication administration training phase 1. Upon successful timely completion of phase 1, the nurse will be able to get an idea of the staff’s competency to passing medications. The employee will then continue on to complete medication certification or do remedial training with the nurse. Currently all non-certified staff at Winifred are enrolled in phase 1 training. Administrative staff (Director and Clinical Coordinator will become med certified to assure back up coverage if needed). The Clinical Coordinator is awaiting to sit for her Exam.

3.	The pharmacy had the refill request in ample time, however, as of September 1st, Medicaid stopped covering the brand name, and only would cover the generic. The generic was on back order.  Upon knowledge of this (after the holiday), program nurse began working with the provider to rewrite the script to read brand name as medically necessary and request prior authorization from Medicaid in order to move forward for medication to be filled.

4.	A locksmith came out on Monday 9/9 to replace the lock and new keys were made. A spare key to the control box was made and is stored in a separate safe to prevent this error from reoccurring. A detailed schedule clearly indicating who is passing medications through the day is posted in the program. When staff complete each med pass on the weekends, they communicate to the program manager, that meds have been successfully passed.

5.	Staff notified manager Saturday morning of compromised lock box, and several attempts were made to unlock key box, including calling a lock smith. However, over the weekend it was difficult to find someone to come in until Monday. To prevent this from reoccurring– A spare key has been made and is kept in a separate safe. Provider was notified.  In the original incident, the box the key was in, was jammed and inaccessible. Having a spare key, would have allowed staff to still get into the med box to give the meds. The spare key can still be kept in the spare safe to be accessible to prevent multiple days of missed meds until a locksmith or maintenance can be brought in to open the jammed box.

6.	To prevent incorrect medication administration errors and improve the immediate notification of any medication error; the ongoing training and oversight provided from the APRN as outlined through the Comprehensive Plan for Medication Distribution and Oversight, specifically learning points 5 (Communication between staff and supervision) and 6 (notification procedures for errors) will be reviewed with staff quarterly for understanding and to create a culture of accountability. Management and Nurse notify DCF Risk Management as outlined in protocol and will notify DCF nursing consultant directly if needed. The new training plan for staff is underway and started 10/16/24  and will continue at a minimum quarterly during staff meetings. RN will conduct trainings for staff 1 on 1 if identified through monthly monitoring of MARS for remediation purposes.
To have more consistent program staff covering medication passes within the program, currently 42% of staff (including the program director) are actively certified with 1 awaiting final certificate. An additional 33% (including the clinical coordinator) of staff are awaiting to take medication certification exam. The remaining staff will continue to be reviewed by the Endorsed Instructor for eligibility. To maintain ongoing staff trained in medication administration, staff will be recommended to begin the phase 1 process within 30 days of hire.

February staff schedule attached reflects all shifts med coverage as of 1/31/25. A 3rd shift staff and another part time 2nd shift staff both are scheduled to test on 2/19

Staff was not allowed to pass medications after the med error occurred until receiving her retraining with Endorsed Instructor Sanah. Sanah conducted retraining of staff on 12/30/24 on the Rule of 3, Five Rights, and reviewed importance of managing the environment during med passes.

Corrections –
1st floor bedroom – new curtains hung and graffiti on the desk was covered up.
2nd floor double bedroom on right – clothes put away in drawers and closets. Broken fan removed, chair with burn marks removed, sheets and mattress/pillow cover replaced. Food/candy wrappers removed.
2nd floor double bedroom left – patches on wall have been painted, electrical switch plate covers have been replaced, clothes have been folded and put in drawers and closets. 2 new dressers are being ordered.

Plan of Action - Reminders with program expectations have been posted in each youth’s room stating there is no food allowed in the room.  Staff will conduct room checks on each shift and sign off that they are completed. Staff each shift will also help maintain cleanliness and order of the rooms by making their beds, putting their clothes away and removing any debris from the floors. Staff will verbally prompt youth to not eat in their room. Staff will be reminded in staff meetings and a written reminder will be placed in the GUTS for staff, that food is not allowed in the rooms and any trash and debris needs to be removed every shift if youth do not comply.

A checklist is maintained for staff to sign off each shift to complete routine cleaning. Daily chore assignments are assigned to each youth on a weekly basis; assigned chore assignments are posted in the hallway and each youth have a chore card to track progress. When their chore is completed, the youth and staff sign off. Daily chores are a way to earn allowance. Major house cleaning is incorporated into the weekend activity schedule to include youth and staff. Incentives have been increased for youth to buy into taking care of their space.

Program Director and Shift Supervisor conduct daily walk throughs while in the program to make sure things are in order.

Corrected - Electrical switch plate was replaced; bathtub was cleaned and has been maintained. Paper towels were replaced, soap dispenser replaced, sink, mirror and all surfaces have been cleaned and continue to be maintained.

Plan of action - A check list is maintained for staff to sign off on cleaning of the bathrooms. Checklist includes reminder to replace paper towels, toilet tissue, hand soap, to wipe down all surfaces and mop floor and tub.

Corrected - Staff have removed any unwrapped food in the refrigerator and freezer. Staff have properly stored all food in containers or used proper storage bags and labeled with dates.

Plan of Action - A check list will be maintained for staff to sign off on cleaning of the refrigerator. A reminder will be posted on the side of the refrigerator for staff and youth participating in meal preparation of proper food storage.

Plan of Action - The dining room table was originally purchased 5 months ago with 8 chairs; 6 for youth and 2 for staff. Due to constant use and some property destruction, 3 chairs were broken. Chairs will be purchased to assure there are 6 seats for youth at all times.

10/16/24 and Ongoing

2/28/25

Completed

10/16/24 and Ongoing

Completed

Completed

Completed

Ongoing

2/19/25

1/31/25

12/30/24

Completed

Completed

10/19/24, Ongoing

10/19/24, Ongoing

10/19/24, Ongoing

Kerisha Prince, APRN, Sanah Gentles, RN

Kyeesha Clayborne/ Director of Residential Services/ Fady El-Hachem, Facilities Coordinator

Ingrid Zahn, Program Director /Fady El-Hachem, Facilities Coordinator

Kerisha Prince, APRN, Sanah Gentles, RN

Director, Sanah Gentles, RN

Ingrid Zahn, Program Director

Ingrid Zahn, Program Director

Kerisha Prince, APRN, Sanah Gentles, RN

Ingrid Zahn, Program Director/ Sanah Gentles, Nurse/Endorsed Instructor

Ingrid Zahn/Program Director

Sanah Gentles, Nurse/Endorsed Instructor

Ingrid Zahn, Program Director

Ingrid Zahn, Program Director
Shaun Samuals, Shift Supervisor

Ingrid Zahn, Program Director

Ingrid Zahn, Program Director

Ingrid Zahn, Program Director|