facility_name: American School for the Deaf / PACES / RT #48

summary: Visit conducted on 1-15-26. Implemented 2 corrective actions.

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

                                    Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):   10:00am-1:20pm      		DATE: 1-15-26

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Director of Student Life
•	Independent Interpreters (3)
•	Sr. Administrative Assistant
•	Facilities Manager
•	Residential Counselor

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

Physical Plant:  Staff facilitated a tour of the North and South Paces dorms:

South dorm:
-Common areas appeared exceptionally clean;
-Bedrooms appeared clean and generally organized;
-Repairs made to damage on walls needs painting;
-Address minor graffiti on living room rocker;
-Wall fidgets have been added to the Sensory Room;
-Key card swipe mechanism is nonfunctioning between red and green pods - outside vendor has been contacted;Crash
bars are working on the door;
-Drawer front missing in green pod kitchen;
-Several plastic laundry baskets contain broken handles;
-Bedroom #8 contains a large amount of empty boxes (client's collection) - to be removed immediately and stored
elsewhere;
-Numerous bedrooms in need of additional storage containers;

North dorm:
-Common areas appeared exceptionally clean;
-Bedrooms appeared clean and generally organized;
-Repairs made to damage on walls needs painting;
-Several plastic laundry baskets contain broken handles;
-Repairs made to damaged walls need painting;
-Wet carpet in front of living room sink - Facilities Manager to follow up;
-Blankets observed placed over windows by residents in some bedrooms in North & South dorms to block light;
Facilities staff to identify uniform window coverings to offer residents;
-Facilities manager reported that remote adjustment of room temperatures is now available to facilities staff;

Milieu Observation:
-Brief interview with 1:1 Residential Counselor in North dorm. Discussed headcount procedures, documentation, SWIS
smart phone app for resident data collection;
-Female client observed sleeping in room N-4 - refused to attend school;
-Lunchtime observed in Cafeteria.

A meeting was held with the Director of Student Life with interpreters present. The following topics were discussed:
•	PACES census: 40 (28 males, 12 females);
•	Commercial washer and dryer to be installed in the Gym building for custodians to launder bedding;
•	Some middle school students residing in South dorm will transfer to Cogswell dorm this winter;
•	Identify space in each pod for storing client's excessive personal effects;
•	Droppings from geese littered the sidewalks between dorms - ASD reportedly has a plan to remove the matter daily;
•	Incident data for the quarter (AWOL, hospital visits, EMS, etc.);
•	Holiday activities offered to residents that remained on campus for the holiday break.
•	Staffing: 14 newly hired residential counselors currently in Orientation - will shadow next week; overnight shift vacancies; Athletics Director position is vacant - Dir. Of Student Life is covering on an interim basis; 1st  shift Dean of Students vacancy; new Sr. Administrative Assistant hired for Residential Dept.;
•	Guardtour quality assurance review for door swipes; headcount documentation;
•	Sports: New England basketball tournament; Girls ESDAA basketball tournament scheduled for February on campus - seven schools will attend; Boys basketball & cheerleader tournament in West Virginia scheduled for next month; Pickleball tournament at Gallaudet University in March 2026; Drone competition' Volleyball tournament;
•	Construction project at campus entrance for new sports facilities; Water shut off for 5 hours;
•	American Sign Language Dept (ASL) - ASL specialist teaching sign language to direct care staff identified by management; to attend class for up to a year (16 staff on 1st shift, 7 staff on 2nd shift, 12 weekend staff, 4 overnight staff);
•	Completed DCF investigation
•	Storing resident suitcases outside of client bedrooms;
•	Identifying a 'storage room' in each dorm; numerous bedrooms identified to add additional storage cabinets.

Corrective Actions implemented as a result of previous visit: A Regulation Compliance Plan was submitted following a semiannual personnel file review conducted last month. The RCP was accepted by the Department.

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

Kathleen Forsythe, LCSW		                      Date:  1-20-26
Regulatory Consultant

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

Cc: 	Asst. Executive Director, CFO, Dir. Student Life|


state: CT

summary: Visit conducted on 12-16-25.

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 American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       9:00am-2:30pm            		DATE: 12-16-25

AGENCY PERSONNEL WHO PARTICIPATED:
      Job Title:
•	Assistant Human Resources Manager

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semiannual personnel file review for the PACES program. Personnel files are extremely well organized.

Forty-seven (47) personnel files were reviewed. The following regulatory deficiencies were noted:

17a-145-64	Personnel policies and procedures.
•	Physical exam: Documentation of a physical exam in one file (SY) indicates the exam was acquired nearly 3 months prior to hire rather than immediately prior to assuming duties.

•	TB test results were not found in one personnel file (JS).

17a-6a. Commissioner to require applicants to submit to state and national criminal history records checks. State child abuse registry checks for applicants.

•	The results of out-of-state child protective services (CPS) checks are missing in two personnel files (JP for New Hampshire, BP for Washington & Wyoming).

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

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

Kathleen Forsythe, LCSW                                  		Date:  	12-18-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director, CFO, HR Director, Asst. HR Manager|


summary: Visit conducted on 11-6-25.

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 American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       11:30am- 1:45pm             		DATE: 11-6-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Director of Student Life
•	Independent Interpreters (2)
•	Sr. Administrative Assistant
•	Facilities Manager

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

Program Update:
•	Census: 39 (10 females, 29 males)
•	Staff vacancies: 13 residential counselors (RC); new employee orientation starts next week with 10 RC's and two teacher's aides expected to attend. Residential department management is complete with seven Dean of Students, two Associate Directors of Student Life and a new Director of Student Life.
•	Incident data reports for the past quarter were reviewed.
•	Cogswell dorm to reopen in the coming weeks for Paces residents.
•	New Autism Center with Medical office.
•	Cook Lodge reopened at the start of the school year for older males.
•	Fall sports; volleyball and soccer tournaments attended at other schools for the deaf; the Deaf Men's National soccer teams for the USA and Germany visited the campus; Paces students attended professional soccer matches at Rentschler Field
•	Halloween activities.
•	Homecoming celebration.
•	Summer 2025 activities; Paces residents visited ASD's Camp Isla Bella; the camp's successful accreditation by the American Camp Association (ACA)
•	Staff personnel file review to be conducted next month.
•	New soccer field under construction near front entrance to campus; current soccer field to be repurposed with pickleball and basketball courts.
•	New Maintenance garage under construction.

Physical Plant:
The Director of Student Life facilitated a tour of the two Paces dorms, with two interpreters, a senior administrative assistant and the facilities Director in attendance.
•	All areas appeared clean and organized.
•	Multiple bedrooms in both North and South dorms contain a large amount of student personal effects - discussed the need for more storage options in bedrooms.
•	Faucet from common room sink in South dorm removed for repair.
•	Vanity and wall at common room sink in North dorm contains water damage.
•	Musty order in a North dorm bathroom to be addressed.
•	Discussed need for privacy curtain/partition in some single bathrooms.
•	Some windows in both dorms contain blankets to block light - discussed need for the agency to identify options to reduce natural light in resident bedrooms if requested.

Milieu Observation: All clients were attending school in the academic building. Cleaning staff were observed in the dorm.

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

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

Kathleen Forsythe, LCSW		                           Date:  11-12-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM.
          Cc: 	Asst. Executive Director, CFO, Dir. Of Student Life, Facilities Manager|


summary: Visit conducted on 7-24-25. Implemented 2 corrective actions.

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

                                     Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       12:00pm-2:15pm		           DATE: 7-24-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Assoc. Director of Student Life (KF)
•	Independent Interpreter
•	Administrative Assistant
•	Dir. Of Operations
•	Facilities Manager

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

A meeting was held with an Associate Director of Student Life with interpreter present. The following topics were discussed:
•	Census: 35 (29 males, 6 females); increase in referrals.
•	Staffing: 5 full time weekend residential counselor positions vacant; overnight nursing coverage to start in August; interviews held for new ASL Specialist Dept.,
•	End of school year June activities; one Paces program graduate.
•	Hair care for residents.
•	Clients' personal money.
•	Residential on-call procedures.
•	Recreation: Lake Compounce season passes; summer trip to Camp Isla Bella; on-campus daily activities.
•	Marketing videos in development; Executive Director currently attending the 2025 DeafNation Expo.
•	Camp Isla Bella underwent accreditation this summer.
•	Autism Center to open in Cogswell dorm with start of new school year - dorm currently under renovation; older Paces residents will move to Cook Lodge to work on life skills development; transportation options to upper campus for Cafeteria and Health Center.
•	Incidents:
o	Increase in restraints in the past three months; outliers discussed (new client, med changes, new behavioral interventions, etc.); suggestions made for specific data collection and analysis as a performance improvement initiative.
O	Hospital visits
o	Calls for emergency services.
•	Discussed male client from NY; risk assessment conducted, 1:1 staffing, treatment interventions developed.
•	Current investigations:
o	Identified staff on admin leave;
o	On-call emergency interpreter availability;
o	West Hartford Police involvement;
o	New York Justice Center;
o	Residential staff sign language skills: Reported number of staff have difficulty communicating with deaf/hard of hearing residents; no current system in place for mandatory sign language training, skills assessment, etc.

Physical Plant:  Staff and facilities personnel facilitated a tour of the North and South Paces dorms:
•	Building interiors cool, though some vacant bedrooms are warm on one side in both dorms; availability of fans for residents if needed.
•	Common areas in both dorms appeared very clean; housekeeping staff observed in dorms.
•	Graffiti on walls in two bedrooms and bedroom closet door in South dorm, as well as wall damage in some bedrooms.
•	Ventilation fans not functional in some bathrooms.
•	Some bedrooms contain large amounts of personal effects; delivery of additional dressers anticipated in September.
•	Pillows on some beds do not contain pillowcases reportedly per student requests, however they are available in bedrooms.
•	Baseboard molding missing in a vacant bedroom in North dorm.
•	Suitcase storage.
•	Old Maintenance garage torn down.

Milieu Observation: A client and 1:1 staff observed in dorm playing cards; other residents observed returning to dorms from on-campus rec activities; staff observed reporting for second shift.

Corrective Actions implemented as a result of previous visit: Regulation Compliance Plan submitted following the spring biannual relicensing inspection. The RCP was accepted by the Department.

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

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

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

Cc: 	Asst. Executive Director, CFO, Assoc. Dir. Student Life, Director of Operations|


raw_content:
April 28, 2025

Mr. Jeffrey S. Bravin
Executive Director
The American School for the Deaf, Inc.
139 North Main Street
West Hartford, CT  06107

Re: Relicensing inspection – PACES Program
Regulatory Consultants: Kathleen Forsythe, Amita Patel, Patrick Hughes, Jim Funaro

Dear Mr. Bravin,
On April 22-24, 2025, a biennial re-licensing inspection was conducted for the PACES program at The American School for the Deaf, located at 139 North Main Street, West Hartford, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Child Caring Regulations 17a-145-48 through 17a-145-124.

Additionally, an onsite review was conducted by DCF Nurse Consultant Errolee Miller, MSN, to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A sample of client medical records was reviewed, and a ‘full standard’ rating of compliance was issued.
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 (RCP) to address each area.  The plan must be submitted to the assigned Regulatory Consultant 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 below.   Also included in the report are recommendations.  Recommendations are meant to highlight areas that are not currently areas of non-compliance but may become non-compliant if actions are not taken.  Recommendations do not require the submission of a regulation compliance plan.

The areas of regulatory noncompliance are as follows:

17a-145-52     	Interstate Placement of Children.
Interstate Compact for the Placement of Children (ICPC) forms were not provided for review for the following student resident: JD.

17a-145-61	     Written Policies and Procedures.
Evidence of the Executive Director's 2024 annual review of policies for the Paces program was not found.

17a-145-73	     Sleeping Accommodations.
Recommendation: It is recommended that the facility add additional storage options in bedrooms for excess clothing/personal effects that do not fit into the closets.

17a-145-86     	Instructions in Safety Procedures. Supervision.
Evidence of fire drill evacuation reports was not provided for the following dorms:
Clerc Dorm:
2023: 3rd shift, 3rd quarter
2024: 3rd shift, 3rd quarter

Holt Dorm
2023: 3rd shift, 3rd quarter

Cogswell Dorm:
2023: 3rd shift, 3rd quarter

	Butterworth Dorm:
2023: 3rd shift 3rd quarter
2024: 3rd shift, 3rd quarter

Recommendation: It is recommended that the facility document the dates a dorm/student residence is closed and dates of any re-opening in fire evacuation records.

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

Sincerely,

Kathleen Forsythe, LCSW
DCF Regulatory Consultant
Licensing Unit
Dept. of Children and Families
505 Hudson street
Hartford, CT  06106
Kathy.forsythe@ct.gov

Copy: 	File
          Asst. Executive Director
	          Assoc. Dir. of Student Life
         CFO|

report_type: unstructured


summary: Visit conducted on 1-16-25.

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 American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       10:00am-12:40pm                           		DATE: 1-16-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Assoc. Directors of Student Life (3)
•	Independent Interpreters (2)
•	Administrative Assistant

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

A meeting was held with the Associate Directors of Student Life with interpreters present. The following topics were discussed:
•	Census: 36 (28 males, 8 females); increase in referrals.
•	Staffing: Two Dean of Student positions and 12 direct care positions are vacant. A vacant Assoc. Director of Student Life position has been filled this week.
•	Staff dress code; provision of agency shirts to direct care workers underway.
•	Decline in physical interventions since move to new dorms in October 2024.
•	Student 20-minute headcount procedures, documentation.
•	Eastern Schools for the Deaf tournament to be hosted by ASD next month; tournaments for basketball and cheerleading scheduled for eight participating schools; housing for visiting teams.
•	Special Olympics; two students to attend Robotics & drone competition in Georgia next month; adaptive ski club.
•	Investigations.
•	Holiday celebration activities last month.
•	Staff survey completed on training topics.
•	Two new ASD buses to be delivered in the coming months; new shared van with Community Interpreters.
•	Biennial DCF relicensing inspection for Paces program scheduled for April 2025.

Physical Plant:  Staff facilitated a tour of the two new Paces dorms.
•	All areas appeared very clean and organized.
•	Broken shower heads (two in North dorm, two in South dorm) reported; parts on order; new non-slip mats installed in bathrooms.
•	Water coolers on order; discussed provisions for drinking water for students in all dorm pods.
•	Some room number plaques missing next to bedroom doors - work orders have been submitted.
•	Discussed emergency preparedness plan for a utilities interruption.
•	Large piles of soil from dorm construction project have been removed from front of campus.

Milieu Observation: Clients were attending school during the visit. Housekeeping staff observed cleaning common areas in both dorms. Lunch observation.

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

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

Kathleen Forsythe, LCSW                                                   		Date:  1-17-25
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director, CFO, Assoc. Dir. Student Life, Director of Operations|


summary: Visit conducted on 12-5-24. Visit covered 1 main areas/topics. No compliance issues identified.

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

                                                   Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       morning                            		DATE: 12-5-24

AGENCY PERSONNEL WHO PARTICIPATED:
  Job Title:
      HR Director

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semiannual personnel file review. Twenty-five personnel files were reviewed. Files are well organized, and no regulatory deficiencies were noted.

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

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

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

Kathleen Forsythe, LCSW                                      		Date:  12-6-25
Regulatory Consultant

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

visit_time: morning


summary: Visit conducted on 10-24-24. Implemented 2 corrective actions.

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

                                                 Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       12:40pm-2:50pm                  		DATE: 10-24-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Assoc. Director of Student Life (JB)
•	Independent Interpreter
•	Administrative Assistant

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

A meeting was held with an Associate Director of Residential Services and an Administrative Assistant with an interpreter present. The following topics were discussed:

•	Census: 33 (25 males, 8 females)
•	Staff vacancies: One Associate Director of Residential Services; approximately 14 direct care positions campus wide.
•	Client incident data for August and September 2024.
•	Dorms:
o	Two new construction dorms (North and South) in the middle of campus were opened this month for Paces residents. Move-in date was 10-14-24.
o	Holt, Cogswell, and Clerc dorms are now closed. No residents living in Cook Lodge or the Cottages.
o	Each new dorms constructed with three color-coded living spaces (pods) with secure entry to each pod.
o	Each new dorm has housing for up to 28 residents. LBC is 8-10 residents per pod.
o	North dorm currently housing two pods of females (4 in each) and one pod of seven males working on independent living skills.
o	South dorm currently housing males in all three pods.
o	Residents reportedly very happy in the new living environment.
•	Homecoming: Held earlier this month. ASD hosted student sports teams at Camp Isla Bella from three out-of-state schools.
•	Clinician coverage during Residential programming: Wednesday through Saturday 1p-9p, Sundays on-call.
•	Fall sports and Special Olympics participation.
•	Student employment on campus.
•	DDS registry checks.

Physical Plant inspection: Staff facilitated a tour of the two new Paces dorms, located directedly behind the GCEC building.
•	Dorm locations provide closer access to the Cafeteria and Student Health Center.
•	Dorms face each other with new lawn space and beautiful landscaping.
•	The three sections (pods) of each dorm are color-coded in either red, green, or orange to represent the colors in the ASD logo.
•	Furniture and bed linens are color-coded to match the living space.
•	All areas in both dorms were observed to be extremely clean, beautifully furnished, and well-organized.
•	New dressers to be purchased to augment closet storage in bedrooms.
•	Privacy coverings added to bedroom windows and at each interior pod entrance.
•	Discussed corded mechanism attached to touchless bathroom sink faucets.
•	No clinician offices currently in new dorms.
•	Ceremonial tree planted in between dorms to contain seasonal lighting throughout the year.
•	Contracted cleaning company; work order system for repairs.
•	Leadership Team: Brief meeting was held with the Executive Director, Asst. Executive Director, CFO and Director of Operations during the tour.

Milieu Observation: Clients were attending school during the visit. One client, who returned early from school, was observed with staff in North Dorm. Second shift staff observed reporting to the dorms for scheduled shift.

Incident Response Note: During the past quarter, Licensing responded to one incident and completed an incident response note. The incident occurred in October 2024 and involved an allegation of abuse reported to the Careline that was not accepted for investigation.

Corrective Actions implemented as a result of previous visit: A Regulation Compliance plan was submitted by ASD regarding personnel files following a July 2024 Licensing visit. The RCP was accepted by the Department.

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

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

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director, CFO, Assoc. Dir. Student Life, Director of Operations|


summary: Visit conducted on 7-11-24. Visit covered 1 main areas/topics. Implemented 1 corrective actions.

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

                                                   Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       10:00am - 1:00pm                            		DATE: 7-11-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Assoc. Director of Student Life (KF)
•	Director of Operations
•	Independent Interpreters (2)
•	Administrative Assistant
•	Asst. Executive Director

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semiannual personnel file review of new hires. An additional Licensing visit was conducted on 7-9-24 to obtain a Paces program update and to tour the Paces dorms.

Personnel File Review: A semiannual personnel file review was conducted on 7-11-24.
o	Seventeen (17) personnel files were reviewed. See 'Areas of Regulatory Non-compliance' below.

During the 7-9-24 Licensing visit, a meeting was held with an Associate Director of Student Life. The following items were discussed:
•	Census:33 residents (8 females, 25 males)
•	Staffing:
o	Vacancies = 1 FT Dean for the weekends.
o	Long-time Assoc. Director of Student Life will be leaving at end of month.
o	New Associate Director of Student Life hired.
o	Status of the pilot 4x4 staffing schedule.
•	Review of behavioral data and incidents from past quarter.
•	End of school year activities: Prom, Senior day trips, graduation of four Paces students.
•	Special Olympics: Athletes (6) competed in track & field event at WCSU; swimming, bocci and golf Special Olympics practices scheduled for the fall.
•	Dormitories:
o	Two new Paces dorms currently under construction, to be completed for the start of new academic year.
o	Cogswell dorm converted this summer to temporary staff & intern housing; will no longer house students.
o	Clerc dorm will house male Core program students in the fall.
o	Holt dorm will no longer house students after new dorms are open.
o	Cottages D & E will no longer house students; currently empty.
•	Summer activities:
o	Majority of Paces students are attending ASD's overnight Camp Isla Bella (IB) this week.
o	Residential dorm staff provide student supervision 24/7 at the camp; Camp IB counselors facilitate camp activities.
o	New Director hired for Camp Isla Bella
o	Scheduled events include Yard Goats game, weekly trips to Lake Compounce, swimming at local pool, water slide and wading pool on campus.
•	Clinical coverage in the evenings.
•	Donation of rec equipment, vehicle, etc. from member of the community.
•	Planned relocation of soccer field to front of campus.

Physical Plant Tour:
•	Conducted on 7-9-24 with an Associate Director of Student Affairs.
•	Butterworth and the main floors of Clerc and Holt dorms were toured.
•	Several unkempt bedrooms observed in Butterworth dorm.
•	Housekeeping staff observed in dorms toured.
•	Window blinds removed from Holt dorm living room; will replace with privacy film.
•	Discussed ensuring Maintenance closets are locked at all times.
•	Clerc dorm bathroom ceiling has been repaired.
•	No regulatory deficiencies were noted.

Corrective Actions implemented as a result of previous visit: A Regulation Compliance Plan (RCP) was submitted by ASD following an April 2024 Licensing visit. The RCP was accepted by the Department.

Areas of regulatory non-compliance identified during 7-11-24 visit:
17a-131. Cardiopulmonary resuscitation training required for persons who directly supervise children.
o	Evidence of CPR certification was missing in one personnel file (SR)

17a-145-64	Personnel policies and procedures.
o	Evidence of credentials for two interpreters (CT, MM) was not found in the personnel files.
o	Evidence of a physical examination and TB testing results that were obtained after hire rather than immediately prior to hire was found in three (3) files (LM, CT, MM).

17a-151. Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
o	Evidence of a national criminal history background check result was not found in any personnel file reviewed.
o	Evidence of a check of the child abuse and neglect registry in any state in which the staff member resided in the five years preceding hire was not found in seven (7) files (SS, NS, DP BS, RC CT, MM).

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

Kathleen Forsythe, LCSW                                     		Date:  7-15-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director, CFO, Assoc. Dir. Student Life, Director of Operations, HR Director|


summary: Visit conducted on 4-18-24. Found 5 compliance issues. Implemented 1 corrective actions.

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

                                                            Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       10:00am - 1:30pm               		DATE: 4-18-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Assoc. Director of Residential Services (KF)
•	CFO
•	Independent Interpreters (2)
•	Administrative Assistant

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

A meeting was held with an Associate Director of Residential Services, later joined by the CFO, with interpreters present. Areas discussed included:

Census = 35 (23 males, 12 females)

Staffing
•	Vacancies = 8
•	Proposed pilot program for new staffing schedule (4 x 4).
•	Staff teams to be scheduled for beginning or end of week.
•	Opportunities for PQI initiatives to measure effectiveness.
•	New schedule allows for overlap on Wednesdays for staff development activities.
•	Revamping Residential program managerial schedule to improve communication, increase coverage.
•	New Director of Student Life position is posted.
•	Clinical staff coverage (2) during Residential program, evenings and weekends; Behaviorist.
•	Challenges in hiring staff with ASL skills.

Treatment plan review schedule, team members.

Review of behavioral data from past quarter; decrease in restraints.

Review of student activities.
•	Monthly workshops provided to students from UCONN Medical School.
•	Bike safety workshop planned with West Hartford police department; donation of bike helmets.
•	Weekend workshops provided by Nursing Dept.
•	Twice weekly cardio activities, biweekly swimming at Bristol YMCA.
•	Adaptive ski program at Ski Sundown, fly fishing.
•	Special Olympics: bowling, basketball, track.

Two new Paces dorms currently under construction.
•	Late Fall revised target date for completion.
•	Display of samples for interior finish work (flooring, tile, colors, etc.)
•	Review of schematic, discussed building design, layout, LBC of 30 students in each dorm.
•	Bathrooms, laundry room in each building.
•	Sensory room in each building to be designed by outside vendor.
•	Leasing washer/dryers; suggestion of commercial grade.
•	Plan for repurposing current Paces dorms when new dorm construction is complete.

Deaf Awareness training activities
•	Outside trainer to provide sessions in coming weeks.
•	Focus on deaf culture, address cultural divide.
•	Increasing ASL training for hearing staff.
•	Suggestion of using peer trainers.

Investigations:
•	Discussion on status of one internal and one DCF investigation.

Physical Plant Tour:
•	Staff facilitated tour of Butterworth, Clerc and Holt dormitories, as well as Cottages D and E.
•	All areas appeared clean and organized.
•	Two female Core program students stay in Clerc dorm on weekends.
•	Two older females reside in Cottage D, three older males reside in Cottage E. Students in cottages working on independent living skills.
•	New hallway water fountain in Clerc dorm.
•	Minor peeling paint on door frame(s) and radiator in Clerc dorm to be addressed.
•	Ceiling remains damaged in Clerc first floor shower room.
•	Window coverings in Clerc dorm for rooms next to parking lot have been enhanced; discussed additional window coverings for bedrooms in dorms that border neighboring houses.
•	Window blinds in Holt room #106 to be replaced.
•	Discussion on addressing rust on surfaces in bathrooms; discussed need to increase ventilation in shower rooms in Paces residences.
•	Broken living room window in Cottage D contains temporary repair; windowpane missing in front door inside sunporch. Back door in Cottage D found open.
•	Ceiling damage in Cottage E living room and bathroom due to possible roof leak at chimney.
See 'Areas of Regulatory Non-compliance' below.

Corrective Actions implemented as a result of previous visit: Regulation compliance plan was submitted following January 2024 Licensing visit and was accepted by the Department.

Areas of regulatory non-compliance identified during this visit:
17a-145-71	Living Room, Lounge.
•	Damage on ceiling above living room fireplace was observed in Cottage E.

17a-145-74. Lavatory facilities. Toilet articles and linens.
•	Peeling paint observed on the ceiling in the first-floor shower room in Clerc dorm. Repeat citation.
•	Damage observed on bathroom ceiling in Cottage E.

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

Kathleen Forsythe, LCSW                             		Date:	4-19-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director, CFO, Assoc. Dir. Residential Services, Director of Operations|

type: general

description: 71 Living Room, Lounge.


summary: Visit conducted on 1-4-24. Found 3 compliance issues. Implemented 1 corrective actions.

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

                                                         Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       10:00am - 3:00pm                        		DATE: 1-4-24

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	Assoc. Director of Residential Services (JV)
•	Director of Operations
•	Director of Student Health Services

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

A meeting was held with an Associate Director of Residential Services (JV) and the Director of Operations. Areas discussed included:
•	Census = 32 (12 females, 20 males)
•	Staffing: 3 part time weekend slots, 1 full-time second shift. Adding two additional Dean of Students positions and two perdiem drivers.
•	Christmas break: home visits, campus rec activities, holidays events.
•	New dormitory construction underway on campus for two new Paces dorms; anticipated opening scheduled for September 2024. Discussed future plans for the two current Paces dorms.
•	New underground electrical wiring project on campus.
•	Recent power outage on campus during Christmas break: Paces students relocated to GCEC building for two days - generator in use. No disruption to programming, Health Services or Cafeteria.
•	Disaster planning, telephones, generators on campus, potentially conducting simulated conditions drill in future.
•	Preparations for impending weekend snowstorm.
•	Launching pilot program to revamp residential staffing schedules.
•	Fire drill schedule and documentation.
•	Sign language immersion class: classes offered twice per month with rep from Gallaudet University; assessing sign language skills for all staff.
•	Recreation: ski trips offered on Wednesdays, swimming at St. Joseph's twice per week, bowling twice per week, sledding on campus, proposed formation of Girl Scout troop this year.
•	Five senior students (2 female, 3 males) residing in two cottages on campus; life skill development.
•	Bed check frequency; Security Dept. daily review of bedroom door access logs.
•	UCONN offering winter workshops on campus for students (health and life skill topics).
•	Drone skill development for identified student.
•	Campus vehicles: key storage, sign out procedures, GPS tracking, internal and external van cameras.
•	Licensing physical plant checklist.

Physical Plant Tour:
•	Staff facilitated tour of Butterworth, Clerc and Holt dormitories, as well as Cottages D and E.
•	Housekeeping staff observed in all three dorms.
•	All areas appeared very clean and organized.
•	Discussed enhancing window coverings in Clerc dorm for rooms next to parking lot.
•	Fire door in Holt dorm stairwell lobby is damaged - letter provided from installation company re: door is back-ordered. Replacement reportedly scheduled for late January.
•	See 'Areas of Regulatory Non-compliance' below.

Meeting held with the new Director of Health Services. Topics discussed included:
•	Staffing is full; the plan to hire two perdiem nurses.
•	Occupational therapy now provided to identified students in the dorms.
•	Implementation  of new Residential Care Cards for dorm staff for improved communication. Cards are individualized for each student. Information includes allergies, medical considerations, diet/meals, ADL, triggers, etc. Cards updated quarterly or more frequently as needed.
•	Nursing rep now attends quarterly treatment team meetings.
•	Department collaboration with Education, Residential, Clinical, and Food Services.
•	Dietician.
•	Proposed plan to train at least three direct care staff to be certified in the DCF medication administration course for use in accompanying students during travel.
•	Medical coverage plan for impending weekend snowstorm.
•	Recent creation of brief medication related videos uploaded to YouTube for parents.
•	Plan to provide medical emergency simulation events for nursing staff in 2024.

Corrective Actions implemented as a result of previous visit: Pending Service Development plan for issues identified with personnel files during Licensing visit last month.

Areas of regulatory non-compliance identified during this visit:
17a-145-74. Lavatory facilities. Toilet articles and linens.
•	Peeling paint observed on the ceiling in the first-floor shower room in Clerc dorm.

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

Kathleen Forsythe, LCSW                            		Date: 1-5-24
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director, CFO, Assoc. Dir. Residential Services|

description: floor shower room in Clerc dorm.


summary: Visit conducted on 12-6-23. Visit covered 3 main areas/topics. Found 10 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 American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       11:00am-1:00pm		DATE: 12-6-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
•	HR Director
•	HR Asst. Manager
•	HR Asst.

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to conduct a semiannual personnel file review.
•	One file of a rehired employee contains documentation that the employee resigned in lieu of termination in November 2020 and is not eligible for rehire. No written information found in the file to support the rehire.
•	Eight personnel files were reviewed for staff hired since August 2023. See Areas of Regulatory Non-compliance below.

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

Areas of regulatory non-compliance identified during this visit:
17a-101. Protection of children from abuse. Mandated reporters. Educational and training programs.
Model mandated reporting policy.
•	Five files (MK, PS, PL, YT, JT) do not contain evidence of participation in the DCF Mandatory Reporter of Abuse/Neglect training program.

17a-131. Cardiopulmonary resuscitation training required for persons who directly supervise children.
•	One file (MK) does not contain evidence of CPR certification.
•	The CPR certification in one file (LR) does not contain the correct first name of the employee.

17a-145-64 Personnel Policies and Procedures.
•	Evidence of a physical exam and TB testing results/chest x-ray results were obtained after hire for three employees (CJ, NB, PS).
•	Evidence of receipt of the personnel policies was not found in one file (PL).
•	The results of a CT criminal history background check were received after the hire date in two files (NB, CG).
•	The results of a CT child protective services background check were received after the hire date in one file (CG).

17a-151. Investigation. Issuance of license or provisional license. Revocation, suspension or limitation
of license. Appeal.
•	Four files (PL, LR, YT, JT) do not contain evidence of a child abuse registry background check from the state where the employee resided in the preceding five years prior to hire at ASD.

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

Kathleen Forsythe, LCSW                                 		Date:  12-8-23
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	Asst. Executive Director,  CFO|


summary: Visit conducted on 10-19-23. Visit covered 9 main areas/topics. No compliance issues identified. Implemented 1 corrective actions.

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

                                                           Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       morning		DATE: 10-19-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
Assoc. Director of  Residential Services
Operations Director
Independent Interpreter

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the Paces residential units. An Associate Director of Residential Services and the Operations Director facilitated the tour.
The Clerc, Butterworth, and Holt dorms were toured, as well as Cottages D and E. Cook Lodge is currently vacant.
•	All areas appeared generally clean and organized.
•	Discussion on securing ensuite bathroom door in Clerc dorm.
•	Dorms decorated for Halloween.
•	Addressing excess paint near radiators in Holt bathroom.
•	Deep clean is scheduled for dorm kitchens.
•	Minor damage to window blinds in some bedrooms.
•	Addressing ceiling damage in bathrooms in Cottages D and E.
•	Organizing storage rooms in dorms.
•	Surveillance camera monitoring for quality assurance purposes.

An Associate Director of Residential Services submitted written quarterly reports to this Regulatory Consultant. Information reported included:
•	Residential counselor vacancies: Two on 2nd shift, one on 3rd shift, five on the weekends.
•	Current Paces census = 33; one pending admission. Two Core residents reside in Paces dorms on the weekends.
•	Some Paces residents participating in fall athletic teams (soccer & volleyball).
•	Paces residents spent a week at ASD's Camp Isla Bella this past summer as day campers.
•	Several Paces residents participated in overnight sessions at Camp Isla Bella, swim sessions at local pools, visits to Lake Compounce.
•	Special Olympics participation (bowling team).
•	Increase in admission referrals for children with autism.
•	Planned construction of two new dormitories for Paces residents this academic year.
•	Quarterly restraint and incident data.
•	Brief power outage during the past quarter.
•	New therapist office opened in Clerc dorm in September; clinical staff hours during residential programming.

Corrective Actions implemented as a result of previous visit: A service development plan from a June 2023 Licensing visit was submitted by ASD in the last quarter and was accepted by the Department.

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

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

Kathleen Forsythe, LCSW                              		Date:  11-2-23
Regulatory Consultant

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

Cc: 	Asst. Executive Director, Assoc. Director of Residential Services, CFO|

personnel: Assoc. Director of  Residential Services


summary: Visit conducted on 7-21-23. No compliance issues identified. Implemented 1 corrective actions.

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

                                                    Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       11:00am-1:00pm                          		DATE: 7-21-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title:
Assoc. Director, Residential Services
Operations Director
Independent Interpreters (2)
Weekend Deans (3)

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

A meeting was held with an Associate Director of Residential Services (KF) with independent interpreters present. The following topics were discussed:
•	Census: Thirty-six residents in the Paces program (26 males, 13 females).
•	Staffing vacancies: Uncertain of exact number, as ASD just completed a very large orientation group. Fourteen interviews scheduled next week.
•	Summer school.
•	Recreation:
o	Camp Isla Bella: Paces residents enjoyed 3-night stay earlier this month; new Camp Isla Bella Director hired
o	Off campus recreation activities (swimming, baseball game, Lake Compounce on Tuesdays & Thursdays)
o	ASD hosting a deaf rap performer in August
•	Graduation: Ceremony held last month, one Paces program graduate.
•	Cottages: One of the cottages was opened in June for two 18-year old residents to focus on independent living skills training.
•	Overnight supervision.
•	Council on Accreditation (COA) successful survey.
•	New dorm construction to begin in the coming months; the plan to re-purpose the Vocational Center.
•	Video cameras; monitoring.
•	Quarterly incident data

Physical plant: Staff facilitated a tour of the Butterworth, Holt, & Clerc dormitories, and Cottage D.
o	All areas appeared generally clean and organized.
o	Window blinds contained minor damage in numerous bedrooms.

Corrective Actions implemented as a result of previous visit: A service development plan from a July Licensing visit to review personnel files is pending.

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

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

Kathleen Forsythe, LCSW                                  		Date:  7-24-23
Regulatory Consultant

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

Cc: 	Asst. Executive Director
Assoc. Director, Residential Services|


summary: Visit conducted on 6-22-23. Visit covered 17 main areas/topics. Found 1 compliance issues.

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

                                                 Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

 TIME OF VISIT (FROM - TO):       9:30am - 3:15pm                     		DATE: 6-22-23

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Training & Onboarding Coordinator
Talent Manager
Human Resources Manager
Assistant Executive Director
Chief Financial Officer

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semiannual personnel file review for the PACES program.

1.	Personnel file review: A semiannual personnel file review was conducted for employees hired since December 2022. See Areas of Regulatory Non-compliance below.

2.	Meetings were held with the Assistant Executive Director and the Chief Financial Officer. Topics discussed included:
-	COA Survey: First accreditation survey by the Council on Accreditation (COA) held earlier in June.
-	Opportunities for improvement identified by surveyors (staff evaluation process, treatment plan, recreation, performance quality improvement, etc.).
-	Strengths reported by surveyors (Board of Directors, communication with staff and students, medication administration, case records, facilities & grounds, décor, emergency response, finances, staff longevity, HR reorganization, transportation, management of technology, etc.).
	Final report due in a month.

•	Proposed Construction of two new dorms:
	Planning & Zoning approval secured, meeting with neighbors, description of pod-style living in the two dorms

•	Policy manual reorganization

•	Revamped 3-week onboarding program for new hires

•	DCF Deaf and Hard of Hearing Committee; ASD membership

•	Increase in deaf and hard of hearing staff members in numerous departments (IT, HR, Business Office, Operations, Finance, contracted food service company, etc.)

•	Trauma-Informed Care
-	'Risking Connections' selected as the trauma-informed care model for ASD
-	Thirty (30) staff trained thus far
-Risking Connections 'train-the-trainer' planned this summer for 8 instructors

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

Areas of regulatory non-compliance identified during this visit:
Thirty-one (31) personnel files were reviewed. The following deficiencies were noted:

17a-145-64	 Personnel Policies and Procedures.
•	Physical Exam results documentation was not found in one file (AW).
•	TB testing results documentation was not found in one file (AW).

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

Kathleen Forsythe, LCSW              		Date:   6-26-23
Regulatory Consultant

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

Cc: 	Asst. Executive Director
       Human Resources Manager|


raw_content:
April 10, 2023

Mr. Jeffrey S. Bravin
Executive Director
The American School for the Deaf, Inc.
139 North Main Street
West Hartford, CT  06107

Re: Relicensing inspection – PACES Program
Regulatory Consultants: Kathleen Forsythe, Keith Bryan

Dear Mr. Bravin,

On April 4-6, 2023, a biennial re-licensing inspection was conducted for the PACES program at The American School for the Deaf, located at 139 North Main Street, West Hartford, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Child Caring Regulations 17a-145-48 through 17a-145-124.

Additionally, an onsite review was conducted by DCF Nurse Consultant Anna Cherian, RN, MSN, FNP-BC to determine the program’s compliance with the DCF Medication Administration Guidelines and the DCF Nursing Standards. A sample of client medical records was reviewed, and a ‘full standard’ rating of compliance was issued.

Listed in this report 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 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.
Eight (8) personnel files were reviewed. The following deficiencies were noted:
•	The personnel file of an intern did not contain documentation of TB test results and a physical exam performed immediately prior to hire.

17a-145-73	Sleeping Accommodations.
•	One bedroom (second floor Holt dorm) was in an unkempt condition and contained a foul odor.

17a-145-86	Instructions in Safety Procedures. Supervision.
Fire drill records for the twenty-four months prior to the relicensing inspection were reviewed.
•	The following fire drill evacuation deficiencies were noted:

Clerc Dorm
2021:	1st shift, 2nd quarter - no residents participated

2022:	3rd shift, 3rd quarter - missing

Holt Dorm
2021:	1st shift, 2nd  quarter - no residents participated

2022:	3rd shift, 3rd quarter - missing

Cogswell Dorm
2022:	3rd shift, 3rd quarter - missing

Cottages
2021:	1st shift, 2nd quarter - no residents participated

2022:	2nd shift, 2nd & 4th quarters - missing
3rd shift for 1st, 2nd, 3rd, & 4th quarters - missing

2023:	1st, 2nd, 3rd shift - missing for 1st quarter

Cook Lodge:
2021:	1st shift, 2nd quarter- no residents participated

2022:	3rd shift, 3rd quarter - missing

17a-145-96	Discharge of a Child.
•	The discharge summary reports were not found in two records reviewed (AW, ES).

•	Evidence was not found in two closed records (LG, AW) indicating that the clients were discharged to the legal guardian, nor was written documentation found from the legal guardian authorizing discharge to another party.

17a-145-98	Case Records. Reports. Confidentiality.
Eleven (11) open case records were reviewed. The following deficiencies were noted:
•	The plan for discharge and disposition is missing on treatment plans in five case records (BA, GC, JLu, JLe, JS).

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

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

Sincerely,

Kathleen Forsythe, LCSW
DCF Regulatory Consultant
Licensing Unit
Dept. of Children and Families
505 Hudson street
Hartford, CT  06106
Kathy.forsythe@ct.gov

Copy: 	File
            Asst. Executive Director
            	Assoc. Dir. of Student Life|


summary: Visit conducted on 3-16-23. No compliance issues identified.

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

                                                             Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

TIME OF VISIT (FROM - TO):       11:00am-3:30pm               DATE: 3-16-23

AGENCY PERSONNEL WHO PARTICIPATED:

            Job Title
Executive Director
Associate Director of Student Life
Independent Interpreters (2)
Interpreter Intern
Assistant Director of Operations
Human Resources Manager
General Manager, Brock Food Services

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

A meeting was held with the Executive Director and the Associate Director of Student Life. Topics discussed included:
•	Census = LBC of 40 beds; Current census = 31 (14 females & 18 males)
•	Staff vacancies: 13 in Residential program;
•	Paces program DCF relicensing inspection scheduled for April;
•	Investigations update;
•	Self-injurious behavior (SIB); SIB training for staff;
•	Health Center: Nursing Director planned retirement in June; seeking two perdiem nurses; occasional use of nursing temp agency;
•	Planned construction of two new dormitories for Paces; anticipated construction dates August 2023 to September 2024; pod design in each dorm; proposed increase in LBC to 50 beds
•	Paces staff/client supervision ratios;
•	Bridge program for graduates; access to campus buildings;
•	CORE program LBC;
•	Vacant cottages available for Departmental needs for deaf and hard of hearing children.

Meeting with General Manager of Brock Food Services. Topics discussed:
•	food prep/serving allergy protocol;
•	beverage dispensing;
•	menus;
•	planned upgrades to serving line;
•	Registered Dietician involvement and coordination with Health Center re: resident dietary issues;
•	milieu observation at lunch time.

Associate Director of Student Life facilitated tour of physical plant with Assistant Director of Operations:
•	First floor Clerc dorm;
•	Tiger Den physical plant safety;
•	Clerc dorm kitchen; food storage.

Brief meeting with the Human Resources Manager:
•	Personnel file review conducted in the Human Resources Department.

Brief meeting with Associate Director of Student Life:
•	Reviewed quarterly client behavior data
•	Provided fire drill evacuation reports for the past two years

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

Areas of regulatory non-compliance identified during this visit:	Not applicable.

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

Kathleen Forsythe, LCSW			                             Date: 3-20-23
Regulatory Consultant

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

Cc:       	Assistant Executive Director
             Assoc. Director of Student Life|


summary: Visit conducted on 12-22-22. No compliance issues identified.

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

                                                              Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

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

AGENCY PERSONNEL WHO PARTICIPATED:
              Job Titles:
•	Employment Specialist
•	HR Manager

List of Areas / Topics covered during visit:  This was a scheduled visit to the Human Resources  Office to conduct a semiannual personnel file review. Eighteen (18) personnel files of staff associated with the PACES program were reviewed. Personnel files are well organized. No regulatory deficiencies were observed.

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

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

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

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
CC: Asst. Executive Director, Director|

visit_time: morning/afternoon

personnel:
•	Employment Specialist
•	HR Manager


summary: Visit conducted on 11-22-22. No compliance issues identified.

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

                                                        Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

 TIME OF VISIT (FROM - TO):       10:30am - 2:00pm               DATE:  11-22-22

AGENCY PERSONNEL WHO PARTICIPATED:
                  Job Titles:
Associate Director of Student Life
Independent Interpreters (2)
Asst. Executive Director
Director of Finance & Operations
Clinical Social Work Coordinator
Assistant Director of Operations
Direct Care Worker - Holt dorm

List of Areas / Topics covered during visit:  This was a scheduled quarterly DCF Licensing visit to obtain an update on the program and tour the residential living units for the Paces program.

Meeting held with the Clinical Social Work Coordinator and an Associate Director of Student Life, with two interpreters present. Topics discussed:
•	Census = 29. New admission from Wisconsin; recent planned discharges
•	Staff vacancies: 5 direct care staff on 2nd shift, 2 staff vacancies on weekends
•	New structure of Residential Department management team, which includes three Associate Directors and three Dean of Students; elimination of Director of Student Life position; new Resident Support Behavior Technician position
•	Student incident data for the quarter
•	Student rec/leisure activities for the quarter
•	Monthly inter-departmental meetings resumed with Clinical, Residential, Nursing, Psychiatrist, Autism services
•	Clinical services in the Paces program; therapeutic support groups weekdays 12:30p-3p, weekend equine therapy for one resident, clinical intern to start in January 2023
•	Life skills assessment in progress for PACES residents
•	Child Trafficking training
•	Transportation vehicles, three new leased vans, large bus
•	Video camera footage review process
•	Gift cards given to families for Thanksgiving

Meeting held with Assistant Executive Director, Director of Finance and Operations and Associate Director of Student Life, with interpreters present. Topics discussed:
•	Proposed construction of two new dorms and two sports courts for the PACES program; funding secured; target date to break ground is June 2023 with completion targeted for June 2024.
•	Draft schematic of proposed dorms reviewed. Pod concept design with single and double bedrooms, kitchenette, laundry facilities, lounges, single person bathrooms; window type, overhead sprinklers, heating/cooling; town zoning, fire marshal, health inspection approvals
•	Proposed underground electrical project; funding secured
•	COA accreditation preparation resumed after delay; proposed COA survey to occur June 2023
•	Animal assisted therapy (two dogs) occurring in the school building two mornings per week
•	QRTP (Quality Residential Treatment Program) preparation for Department approval
•	Risking Connections trauma focused training to begin January 2023, 18-month roll out schedule; Train-the-Trainer sessions

Physical plant tour of PACES residential living units (Clerc, Holt and Cogswell dorms) with interpreters, Associate Director of Student Life and Assistant Director of Operations. All areas appeared clean and organized. Contracted cleaning staff observed in two dorms. Areas discussed:
•	Enhancing bedroom window privacy
•	Adjusting treatment plan for student refusing to attend school
•	Brief interview with direct care worker re: student supervision
•	Thanksgiving celebration plans, home visits
•	Providing additional storage cabinets in identified bedrooms

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

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

Kathleen Forsythe, LCSW			                            Date: 11-23-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
CC: Asst. Executive Director, Associate Director of Student Life, Director of Finance & Operations|


summary: Visit conducted on 8-26-22. Visit covered 18 main areas/topics. No compliance issues identified.

raw_content:
Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: The American School for the Deaf - PACES Program

 TIME OF VISIT (FROM - TO):       9:30am-1:00pm               DATE:  8-26-22

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
Executive Director
ASD Interpreter
Asst. Executive Director
Associate Director of Student Life
Interim Associate Director of Student Life
Director of Finance & Operations
Asst. Director of Operations
Resident
Independent Interpreter

List of Areas / Topics covered during visit:  This was a scheduled quarterly DCF Licensing visit to obtain an update on the program and tour the residential living units.
•	Meetings held with Executive Director and Interim Associate Directors of Student Life
•	Restructuring of Residential Management positions for weekends
•	Weekly Student Life meeting
•	Staff vacancies, hiring incentives, pay scale
•	Physical plant tour of Cook Lodge, Cogswell dorm, Clerc dorm & Holt dorm
•	Creation of post-graduate living center
•	Milieu observations; client interview
•	Camp Isla Bella summer camp
•	Summer recreation activities
•	Completion of new parking area at Cogswell dorm
•	Completion of IT/HR/Business office renovation
•	Installation of new AC unit at Cogswell building
•	New resident computer room in Cogswell dorm
•	Anticipated installation of door alarm at Cogswell dorm
•	Mattresses
•	Fall sports program
•	Incident data for the quarter

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

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

Kathleen Forsythe, LCSW			       Date: 8-29-22
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
CC: Asst. Executive Director, Interim Director of Student Life|


summary: Visit covered 2 main areas/topics. No compliance issues identified.

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

Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:        The American School for the Deaf, Inc. - PACES program

TIME OF VISIT (FROM - TO)		afternoon	                                DATE:  6-23-22

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
HR Manager

List of Areas / Topics covered during visit:
•	Scheduled remote semiannual personnel file review
•	Ten personnel files reviewed for compliance with DCF Licensing regulations

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

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

Kathleen Forsythe, LCSW                                                                     				Date: 6-23-22
______________________________
Regulatory Consultant

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM
Cc: 	File
     	Asst. Executive Director
Supervisor of IT, Campus Security & Infrastructure|


summary: Visit conducted on 5-31-22. No compliance issues identified.

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

Field Visit Reporting Form

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

 NAME OF FACILITY / PROGRAM: The American School for the Deaf, Inc. - PACES Program

 TIME OF VISIT (FROM - TO):      11:30am-3:00pm               DATE: 5-31-22

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Director of Student Life
Interim Assistant Director of Student Life
Education/Residential/Clinical (ERC) Liaison
Supervisor of IT, Campus Security & Infrastructure
Independent Interpreter (HC)

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

A meeting was held with some members of the administration who provided an update on the PACES program. An independent interpreter was present for the meeting.

List of Areas / Topics covered during visit:
•	Review of February-April 2022 student behavioral data
•	Performance Improvement
•	Direct care staff vacancies
•	Current group counseling for girls; planned topics for summer & fall
•	Student personal cell phone use
•	Staff cell phone use
•	New DCF physical plant checklist
•	ECR Coordinator recently served as the Assistant Women's Basketball Coach for the Deaf Olympics, held in Brazil, at which Team USA won a gold medal
•	ASD's Camp Isla Bella scheduled to open this summer with two sessions; Paces students to visit in July; ECR Coordinator to serve at Camp Director for five weeks
•	End of school year activities: recreation, awards, Prom, Graduation
•	Recent acquisition of CEASD (Conference of Educational Administrators of Schools and Programs for the Deaf) Accreditation for three years
•	Suicide Prevention Physical Plant Audit Report by an outside consultant completed in Spring 2022
•	Construction in Cogswell building; planned move of several departments (IT, Human Resources, Plant Operations, Administrative offices) into the renovated space scheduled for late summer 2022
•	ASD hosting events in summer 2022: U.S women's tryouts for the Deaf Olympics; Gallaudet basketball camp
•	Age waivers for two female clients
•	Streamlining transportation

A tour of Paces living units (Holt, Clerc and Cogswell dorms, Cook Lodge) was facilitated by the Interim Assistant Director of Residential Life. The Supervisor of IT, Campus Security & Infrastructure joined for a portion of the tour and reported on the following:
•	Campus tree trimming currently underway
•	Renovation of Cogswell lower level by an outside contractor
•	Plans for the construction of two new dorms on campus, schedule to begin in summer 2023
•	Driveway repair near Cogswell building
•	Interior dorm painting schedule
•	New lounge furniture purchased for dorms
•	Planned expansion of classrooms in Vocational building and new STEM Center

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

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

Kathleen Forsythe                                                       				6-1-22
______________________________            _________________
Regulatory Consultant                                                 Date

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


facility_name: Boys & Girls Village / Safe Haven / CCF-RT#153

summary: Visit conducted on 11-4-25. Found 5 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:  Boys & Girls Village, Inc. - Safe Haven RTC

TIME OF VISIT (FROM - TO):    9:30am-2:30pm		    DATE:  11-4-25

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	VP of Human Resources
•	VP of Administrative Operations

List of Areas / Topics covered during visit:  This was a scheduled Licensing visit to conduct a semi annual personnel file review, obtain an update on the program, and tour the physical plant.

Personnel File Review: A personnel file review was conducted with the VP of Human Resources for new staff hired for the Safe Haven program.
•	Seventeen personnel files were reviewed. See 'Areas of Regulatory Non-compliance' below.

Physical Plant: A meeting was held with the VP of Administrative Operations who facilitated tour of the residence. Topics discussed included:
•	Census: 13
•	Staff vacancies: 1 part time mental health worker; 2 milieu supervisors for the campus
•	Current DCF investigation; Staff supervision stations.
•	Clients on enhanced supervision status: process, definitions, email communication to staff.
•	Incident data.
•	All areas of the residence appeared very clean and organized.
•	Bedding: Numerous bed comforters supplied by the agency appeared quite worn; extra bedding available on lower level.
•	Water on floor in a client bathroom, recurring issue.

Milieu Observation: One client was observed in the lounge with an assigned staff member. Staff were observed reporting for second shift.

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

Areas of regulatory non-compliance identified during this visit:
17a-101 	Protection of children from abuse. Mandated reporters. Educational and training
programs.
•	Evidence of completing mandatory training of abuse and neglect reporting is missing in one file (MM)

17a-145-64	Personnel policies and procedures.
•	Evidence of receipt of the agency personnel policies is missing in one file (MM).

•	The   results of tuberculosis testing in one file (LG) were obtained more than four months prior to hire rather than immediately prior to assuming duties.

17a-151 	Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	The results of an out of state background check report of the child abuse and neglect registry in any state in which a person or individual resided in the preceding five years was not found in two files (LG, EW).

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

Kathleen Forsythe, LCSW				                                  Date:  11-7-25
Regulatory Consultant

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

Cc: 	VP of Administrative Operations
       File|


summary: Visit conducted on 8-6-25. No compliance issues identified.

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

                                         Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM:  Boys & Girls Village, Inc. - Safe Haven RTC

TIME OF VISIT (FROM - TO):     12:00pm-1:45pm               		DATE:  8-6-25

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

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

A meeting was held with the VP of Operations. Topics discussed included:
•	Overview of Safe Haven program.
•	Census= 14
•	Staff vacancies: 3 full time direct care vacancies; perdiem pool available.
•	Incident data for the quarter.
•	Client/Staff supervision ratios.
•	Average length of stay.
•	Data collection; utilizing data analysis in clinical work; PQI process.
•	Motivational interviewing; consultant; staff training/coaching.
•	Recent upgraded hardware for video surveillance system.
•	Request to review program policies & procedures.
•	On-campus recreation, certified ROPES course.
•	Weekly generator testing, power back-up.
•	Requested follow-up to a non-accept Careline report.
•	Brief introductions to CEO, HR Director, Residential Manager.
•	Monthly Family Night: family training, motivational interviewing, high turnout.
•	Summer program schedule.
•	School expansion project nearly complete for fall opening.

Physical Plant: VP of Operations facilitated tour of the residence.
•	All areas appeared very clean and organized.
•	Brief meeting with Director of Residences.
•	Discussed headcount procedures, frequency, documentation; staff supervision stations; delayed openings on emergency exits; bathroom/shower supervision procedures.
•	Bathrooms: Soap and electronic hand dryers present in all client bathrooms; standing water observed on one bathroom floor - VP of Operations to follow up.
•	Individual hygiene baskets.
•	Food services.
•	Metal detector structure in entry vestibule for visitors.
•	Nursing/medication room not observed; med admin staff discussed.
•	Meditation room.

Milieu observation:
•	Clients observed with staff in Community room participating in Life Skills group.
•	Brief interview with one client who reported very positive experience in the program.

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

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

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

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

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

Cc: 	VP of Operations
      Director of Residency Services
      File|


summary: Visit conducted on 5/29/25. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     1:30pm to 2:30pm               DATE: 5/29/25

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations
	Campus Milieu Director

List of Areas / Topics covered during visit:
•	LBC 14.  Census is 14.  April 29, 2025, the Safe Haven license was amended to increase the LBC from 12-14 males.
•	One vacant position on first shift. Program uses per diem staff to provide coverage
•	Physical plant rooms inspected, and no concern found.
•	Discussed supervision of all youth and ages.
•	Followed up on restraint that occurred 5/18/25.  Youth stated he was choked by a staff member during a restraint.  Video footage of incident reviewed, but did not substantiate allegation. Staff noted youth observed staff making a verbal intervention to another resident, but thought it was directed at him, which it was not.  Youth took the moment to attack staff.  Met with Campus Milieu Director regarding incident. He stated he has already begun training staff on restraint and supervision of youth.  See below.

Corrective Actions implemented as a result of previous visit:

Areas of regulatory non-compliance identified during this visit:
Sec. 46a-152. Physical restraint, seclusion and use of psychopharmacologic agents restricted. Notification of parent or guardian of physical restraint or seclusion of child required. Monitoring and documentation required.
Evidence: A Video clip of the 5/18/25 restraint was viewed by this Regulatory Consultant; the youth was physically escorted into his room by two staff.  Youth attempted to leave several times, but staff pushed him back into the room.  A physical restraint ensued, and several staff needed to intervene. By observation of the video, the staff did seclude the youth.  There is no documentation found in the case record a seclusion was required and happened.

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                           6/3/25
Regulatory Consultant                         Date

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


summary: Visit conducted on 1/28/25. Visit covered 6 main areas/topics. Found 1 compliance issues. Implemented 1 corrective actions.

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

Field Visit Reporting Form

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

  NAME OF FACILITY / PROGRAM: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     1:30pm to 2:30pm               DATE: 1/28/25

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 14.  One youth is in the hospital. Two youth admitted under a waiver due and over capacity.
•	One vacant position on first shift.
•	Followed up with substantiated SIU report.  Agency created a new policy and procedure when there is an allegation of abuse and neglect.
•	Physical plant rooms inspected, and no concern found.
•	Discussed supervision of all youth and ages. No concern.
•	Followed up on restraint that occurred 1/19/25.  Program noted that the staff member that initiated the restraint did not follow TCI training and company procedures, employee terminated from employment at BGV.  Program Vice President will follow up with staff to retrain and ensure proper procedures are followed.

Corrective Actions implemented as a result of previous visit:
10/22/24 and 10/23 /24 a biennial re-licensing inspection
Section 17a-145-73. Sleeping accommodations.
Evidence: During the inspection, the window in room 1BD was found to have numerous large cracks. The window should be repaired / replaced to look like and be in similar condition as other youths' room.  Program noted the window supplier was contacted and new window will be purchased and installed.  Date and time to be determined.   Please notify the department when the window is installed.

17a-16-8. Use of the telephone.
Evidence: Based on 9 records reviewed, it was found the program documents telephone conversations of youth on a 'phone contact monitor sheet'.  There is no evidence a youth is on a phone restriction despite call monitored by staff.

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

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

Thomas S. Cuchara                           4/23/25
Regulatory Consultant                         Date

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

description: No RCP


raw_content:
Kim Shaunesey, PhD.							10/24/2024
Executive Director
Boys & Girls Village Inc.
528 Wheelers Farm Rd.
Milford, CT 06461

Re: Licensing Inspection for CCF BGV Safe Haven RTC
      Regulatory Consultants: Tom Cuchara, Jim Funaro & Penny Woodward

Dear Dr. Shaunesey,

On 10/22/24 and 10/23 /24 a biennial re-licensing inspection was conducted at 528 Wheelers Farms Road, Milford, 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 Regulatory Compliance Plan to address each area.  The plan must be submitted within 30 days of receipt of this letter and should identify: 1. the steps to be taken to correct the non-compliance; and 2. the date the correction(s) will be completed.  The areas of non-compliance are listed on the attached DCF Licensing Report form. Please use this form to submit the Regulatory Compliance Plan as well.  Also included in the report are recommendations.

Section 17a-145-73. Sleeping accommodations.
Evidence: During the inspection, the window in room 1BD was found to have numerous large cracks. The window should be repaired / replaced to look like and be in similar condition as other youths' room.  Program noted the window supplier was immediately contacted and a new window will be purchased and installed.  Date and time to be determined.   Please notify the department when the window is installed. Licensing will follow up on subsequent quarterly visits.

17a-16-8. Use of the telephone.
Evidence: Based on 9 records reviewed, it was found the program documents telephone conversations of youth on the a 'phone contact monitor sheet'.  There is no evidence a youth is on a phone restriction despite call monitored by staff.  In addition, the policy and procedure does not clearly stipulate it is a right of all youth to use the telephone.

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

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

Sincerely,

Thomas S. Cuchara
Regulatory Consultant

Copy: file|


summary: Visit conducted on 9/13/2024. 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: Boys and Girls Village / Safe Haven Residential

 TIME OF VISIT (FROM - TO):     12pm to 1:30pm               DATE: 9/13/2024

 AGENCY PERSONNEL WHO PARTICIPATED:

	Job Title
	VP of Administrative Operations
	Milieu Supervisor
	VP Residential Services

List of Areas / Topics covered during visit:
•	LBC 12.  Census is 13.  One youth admitted under a waiver due to age and over capacity.
•	One vacant position on first shift.
•	Youth were at school at the time of visit.
•	Physical plant rooms inspected and no concern found.
•	Discussed supervision of all youth and ages. No concern

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

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                           9/17/24
Regulatory Consultant                         Date

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

description: No SDP