summary: Visit conducted on 11-14-24. 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: CT Clinical Services d/b/a Turnbridge Woodside Circle Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:00am-12:35pm               DATE:  11-14-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Director of Nursing
•	Client

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

A meeting was held with the Clinical Director and Senior Operations Manager. Topics discussed included:
•	Census: 11 males. The program is full.
•	Staffing: One Clinical Liaison vacancy; Maintenance person hired for interior painting.
•	Daytime programming transitioned to co-ed earlier this month; female clients reside in another house on campus.
•	Client grievance procedure.
•	Fire drills.
•	Three calls for police/emergency services in the quarter; one restraint.
•	Revamped clinical curriculum; coping skills group added; group therapy sessions are now held by gender.
•	Heated swimming pool closed last month.
•	Brief loss of power earlier this week - automatic generator activated.
•	Transgender client assigned to single bedroom with ensuite bathroom.
•	DCF-involved client successfully completed program and transferred to a Turnbridge step-down/extended care program late last month.
•	Semiannual personnel file review to be conducted next month.

Milieu:
•	Lunch prep observed.
•	Brief interview with one male client who reported positive feedback on milieu safety, food quality, clinical services, and staff interactions.

Physical Plant: Staff facilitated a tour of the physical plant interior.
•	All areas of the Woodside Circle house appeared very clean and organized.
•	Campus is beautifully landscaped.
•	Maintenance staff observed painting a bedroom.
•	Contractors on site upgrading shower plumbing in two bathrooms.
•	Several new furniture pieces observed in common areas.
•	Snack trolleys located on all floors of house.
•	New washer and dryer.
•	Broken windows blinds in some bedrooms to be addressed.

Nursing:
•	Brief interview with APRN/Director of Nursing and a registered nurse.
•	Director of Nursing now qualified to administer sublocade.
•	APRN medication dispensing.
•	DCF nursing orientation completed since last Licensing visit.
•	Nursing coverage 24/7.
•	Storage and destruction process for unused controlled medication.
•	Medication refrigerator.

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

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

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

Kathleen Forsythe, LCSW                               			Date: 11-19-24
Regulatory Consultant

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

Cc: 	File
      Operations Manager
      Clinical Director|


state: CT

facility_name: CT ClinicalServices dba Turnbridge/#169WoodsideCir

summary: Visit conducted on 8-7-24. 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: CT Clinical Services d/b/a Turnbridge Woodside Circle Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:15am-1:00pm               DATE: 8-7-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Clients
•	Kitchen Staff
•	Education Coordinator
•	Director of Nursing

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

A meeting was held with the Clinical Director. Topics discussed included:
•	Census: 11. The program is full.
•	Average length of stay
•	Staffing: There are no staff vacancies. Program added several positions this year, shared with Washington Road program (Care Team Director, Discharge Planner, Clinical Liaison for after-hours).
•	One significant event in the quarter.
•	Summer activity schedule; special events on campus; staffing model change; small group activities
•	New Director of Nursing joined the meeting. Discussed aspects of DCF Nursing Standards, Medication Administration Guidelines and available DCF Nursing Orientation.
Milieu:
•	Brief interview with Kitchen staff; lunch prep observed.
•	Brief interviews conducted with three clients who reported satisfaction with the program, continued positive praise for food services, and helpfulness of staff. No safety issues reported when asked.

Physical Plant: Senior Operations Director facilitated a tour of the physical plant.
•	All areas of the Woodside Circle house and Education/Gym building appeared very clean and organized.

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

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

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

Kathleen Forsythe, LCSW			Date: 8-8-24
Regulatory Consultant

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


raw_content:
June 10, 2024

Mr. Brett Tiberio
President
CT Clinical Services, Inc. d/b/a Turnbridge
189 Orange Street
New Haven, CT  06510

Re: License # CCF/RTC 169

Dear Mr. Tiberio,

A biennial relicensing inspection was conducted for the Turnbridge Woodside Circle adolescent male residential treatment program June 4-6, 2024, which included a nursing review by a DCF Nurse Consultant.

It was determined that all areas of the program are in compliance with the DCF Regulations for the Operation of Child Caring Agencies and Facilities, as well as the DCF Nursing Standards.

As a result, the enclosed license is issued effective 8-24-24, and is valid for a period of twenty-four months.

I thank you and your staff for the cooperation extended to me during the relicensing process. Should you have any questions, please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe, LCSW
DCF Regulatory Consultant
Dept. of Children and Families
Licensing Unit
505 Hudson Street
Hartford, CT   06106
C: 860-937-7551

Cc: File|

report_type: unstructured


summary: Visit conducted on 5-23-24. No compliance issues identified. Implemented 1 corrective actions.

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

                                                    Field Visit Reporting Form

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

NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Woodside Circle Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:30am- 1:00pm               DATE: 5-23-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Clients
•	Kitchen Staff
•	Research Assistant
•	Chief Clinical Officer
•	Wellness Coordinator
•	Direct Care Staff
•	Care Team Coordinator

List of Areas / Topics covered during visit:  This was a scheduled Licensing site visit for the biennial relicensing inspection scheduled for early June 2024.

A meeting was held with the Senior Operations Manager and the Clinical Director. Topics discussed included:
•	Census: 11. The program is full.
•	Staff vacancies: 0
•	One hospital visit involving a Woodside client during the quarter and subsequent discharge.
•	Outcome of recent DCF investigation for Woodside Circle.
•	Heated swimming pool at Woodside opened in April 2024; six certified Lifeguards on staff; pool company conducted inspection; lifeguard attire; swimming times scheduled minimally three times per week on second shift and weekends; pool rules; client swim tests; need for increased first aid supplies and biohazard spill kit at pool.
•	CARF triennial survey during the past quarter -  successful 3-year accreditation period awarded.
•	Fire drill evacuation reports; frequency; review of reports for the licensed period completed.
•	Records review for relicensing inspection in June; nursing review, exit meeting offered.

Milieu:
•	Kitchen staff interviewed.
•	Brief interviews conducted with several clients. Clients were polite and well-mannered. All reported satisfaction with the program, positive praise for the food served and helpfulness of staff. No safety issues reported when asked.

Physical Plant:
•	Staff facilitated a tour of the physical plant.
•	The grounds and landscaping are exceptional.
•	All areas of the house appeared very clean and organized.
•	New furniture secured for the library/intake room.
•	Leather couch on second floor is repaired.
•	Swimming pool: Retractable cover in place whenever pool is not in use; new cover on order; safety equipment inspection (life jackets, Shepard's Crook, pool divider buoys, backboard, lifeguard rescue tubes); mini first aid kits, pool deck furniture, landscaping, outdoor fire pit utilized under supervision of Rec staff.
•	New seat cushions on wingback chairs in second floor hallway.

Corrective Actions implemented as a result of previous visit:  A Regulation Compliance Plan (RCP) was submitted to the Department following a February 2024 Licensing visit to the Woodside Circle program. The RCP was accepted.

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

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

Kathleen Forsythe, LCSW                             			Date: 6-3-24
Regulatory Consultant

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


summary: Visit conducted on 2-15-24. Visit covered 27 main areas/topics. Found 4 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                                Program -Woodside Circle, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:30am-1:20pm               DATE: 2-15-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Operations Director
•	Clinical Director
•	Client
•	Maintenance staff
List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing Visit to obtain a program update and to tour the physical plant.
•	Census=11. Program is full; waiting list; average length of stay.
•	Staffing: One full time staff floater vacancy; new Wellness/Recreation Coordinator hired; New Resident Liaison/case manager added on second shift; two cleaners hired.
•	Three EMS calls since last Licensing visit.
•	Recent holiday activities.
•	Winter storm preparedness.
•	Neighbor called police due to clients trespassing during a supervised nature hike.
•	Campus recreation activities; assessing staff competence in use of fitness room weights.
•	CARF triennial survey held last week.
•	Daily program schedule, fitness activities, educational programming.
•	DCF relicensing inspection scheduled for June 2024.
•	New vehicle purchased to share with another program on campus.
•	Residents observed during a program break prior to lunch.
•	Lunch prep: chicken-vegetable stir fry; grilled cheese sandwiches and tomato soup; salads.
•	New group therapy chairs.

Staff facilitated a tour of the physical plant. See 'Areas of Regulatory Non-compliance' below.
•	All areas appeared clean and organized.
•	Exterior walkways and driveways free of snow and ice.
•	Recommendation to install video camera in library.
•	Evidence of numerous recent unpainted repairs to wall damage in bedrooms and lower-level bathroom.
•	Storage of hygiene products in bathrooms.
•	Discussion on utilizing alternative materials for interior walls prone to damage.
•	Temporary repair to broken bedroom window; replacement window on order.
•	Mold and peeling paint noted on a ceiling in a second-floor bathroom.
•	Window blind slats damaged in some bedrooms.
•	Brief interview with client from Colorado; two other clients expressed satisfaction with the program.

Corrective Actions implemented as a result of previous visit:  A service development plan was submitted to the Department following a December 2023 personnel file review. The SDP was accepted.

Areas of regulatory non-compliance identified during this visit:

17a-145-71 	Living Room, Lounge
•	A seat cushion on leather couch in second floor lounge is torn.

17a-145-74. Lavatory facilities. Toilet articles and linens.
•	Peeling paint and mold observed on the ceiling in a second-floor bathroom. Lightbulb missing from ceiling light.

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

Kathleen Forsythe, LCSW                                   			Date: 2-20-24
Regulatory Consultant

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

type: general

description: 71 Living Room, Lounge


summary: Visit conducted on 12-7-23. Visit covered 1 main areas/topics. Found 2 compliance issues. Implemented 1 corrective actions.

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

                                             Field Visit Reporting Form

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

NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                       Program -Woodside Circle, Woodbury, CT

 TIME OF VISIT (FROM - TO):       8:00am-10:30am               DATE: 12-7-23

 AGENCY PERSONNEL WHO PARTICIPATED:
•	HR Department
•	Executive Director

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review conducted remotely.

Six personnel files were reviewed of staff hired since July 2023. See Areas of Regulatory Non-compliance below.

Corrective Actions implemented as a result of previous visit: : A service development plan was submitted to the Department following an October 2023 Licensing visit. The SDP was accepted.

Areas of regulatory non-compliance identified during this visit:
17a-145-22	Personnel Policies and Procedures.
The following deficiencies were noted:
•	Documentation of a physical exam and TB testing results were not completed immediately prior to rehire in one file (AS).

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: 12-7-23
Regulatory Consultant

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


summary: Visit conducted on 10-5-23. Visit covered 12 main areas/topics. 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                  Program - Woodside Circle, Woodbury, CT

TIME OF VISIT (FROM - TO):       10:30a- 12:15pm         		DATE: 10-5-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Clinical Director
•	Operations Manager
•	Clients (8)
•	Chef
•	APRN & RN
•	Shift Supervisor
•	Educational Coordinator
•	Education Paraprofessional

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

?	A meeting was held with the Operations Manager and the Clinical Program Director. Topics discussed included:
•	Census = 11 males from six different states - Program is full.
•	Staff vacancies: Half-time Ropes Course Coordinator.
•	Emergency planning procedures for winter weather.
•	Review of incidents and emergency calls since last Licensing visit.
•	DCF Monthly restraint/seclusion reporting requirement.
•	New weekday program schedule in new academic/fitness building.
•	Heated swimming pool repair during the summer; pool scheduled to close mid-October.
•	Wildlife.
•	Staff lunch bag stored in program refrigerator.

?	Milieu Observation: Lunch prep, group therapy, free time. Group interviews with residents. Positive feedback from residents interviewed on the program.

?	Brief meeting with APRN re: suboxone.

?	Physical Plant tour: Management facilitated a tour of the physical plant and the new academic/fitness building. All areas appeared clean and organized. See Areas for Regulatory Non-compliance below.

Corrective Actions implemented as a result of previous visit: A service development plan was submitted to DCF by the Turnbridge Woodside Circle program following a July 2023 Licensing visit that addressed regulatory citations related to personnel files. The plan was accepted by the Department.

Areas of regulatory non-compliance identified during this visit:
17a-145-76	Sleeping Accommodations.
•	Graffiti observed in some bedrooms.
•	Broken sink vanity cabinet in en suite bathroom inside one bedroom.
•	Unpainted wall repairs in several bedrooms, hall.
•	Hole in wall behind door in bedroom #6.

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

Kathleen Forsythe, LCSW                                   			Date:  10-10-23
Regulatory Consultant

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

Cc:	File
	Clinical Program Director
	Operations Manager|

description: 76 Sleeping Accommodations.

description: Graffiti observed in some bedrooms.

description: Hole in wall behind door in bedroom #6.


summary: Visit conducted on 7-18-23. 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                          Program -Woodside Circle, Woodbury, CT

 TIME OF VISIT (FROM - TO):       9:30am-12:00pm               DATE: 7-18-23

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Operations Director
•	Clinical Director
•	Chef
•	Clients

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

A meeting was held with the Clinical Director and Director of Operations. Topics discussed included:
•	Census: 11 males. Program is full.
•	Staffing vacancies: 0. One full time vacancy anticipated.
•	Family visitation schedule on Tuesday and Thursdays.
•	Client incidents during the quarter (calls for EMS).
•	Recreation: On campus activities, swimming pool, ROPES course.
•	New building on campus scheduled to open next week. Contains education rooms, gym, and offices.
•	Full time contracted house cleaner; additional part time cleaner to be hired in near future.
•	Review of Lifeguard certifications for six (6) Lifeguards on Turnbridge staff.
•	Client search  and drug testing procedures.
•	Laundry procedures.
•	Client intake procedures and physical exams; waitlist, average length of stay
•	Staff/Client ratio during visit: 1:3
•	One agency vehicle available shared with another program on campus.

Physical Plant: Staff facilitated a tour of the physical plant.
•	All areas appeared generally clean and organized. Home is beautifully decorated.
•	Minor damage to couch, coffee table, dining chair and several window blinds observed.
•	Review of safety equipment at outdoor swimming pool.
•	Fire safety protocol discussed for outdoor fireplace.

Milieu Observation: Group therapy; break time; lunch time; new admission tour by peer and staff.

Client Interviews: One client was interviewed. No concerns reported. Client feels program is helpful.

Semiannual Personnel File Review: A personnel file review was conducted prior to the visit. 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-145-22	Personnel Policies and Procedures.
Five personnel files were reviewed for the home at Woodside Circle. The following deficiencies were noted:
•	Documentation of a physical exam and TB testing results were not completed immediately prior to hire in four files (TR, SM, JS, AS).

•	One file (SM) does not contain evidence of a criminal history background check conducted through the CT State Police. Additionally, two files (TJ,  JR) contain evidence that the criminal history background check through the CT State Police was conducted more than four months after hire.

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

Kathleen Forsythe, LCSW                                          			Date: 7-19-23
Regulatory Consultant

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


summary: Visit conducted on 4-13-23. Visit covered 12 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                       Program -Woodside Circle, Woodbury, CT

TIME OF VISIT (FROM - TO):       10:30a-1:00pm                      		DATE: 4-13-23

 AGENCY PERSONNEL WHO PARTICIPATED:
                                        Job Titles:

Clinical Director
Director of Operations
Clients (2)
Director of Culinary Services

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

?	A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included:
•	Census = 11 males - Program is full.
•	No nursing or direct care staff vacancies; additional Educational Coordinator recently hired
•	Behavior management systems; reward system
•	Lifeguards, pool safety equipment, client swim tests
•	New gymnasium/school building on campus -  construction to be completed next month
•	EMS visits in the past quarter
•	Case record review conducted remotely on 4-12-23
•	Swimming pool company onsite during visit to inspect the pool and prepare for seasonal opening
•	Improvements to the physical plant
•	ROPES course, recreation activities

?	Meeting held with Culinary Services Director. Topics discussed: weekly menu cycle and approval, food allergy accommodations, food purchase and storage, soliciting client input on menus.

?	Milieu Observation: Lunch prep, lunch and interviews with two clients - Positive feedback from residents interviewed re: staff, clinical services, food, recreation.

?	Physical Plant tour: Graffiti observed on closet door in a client bedroom; recent repairs to walls in some bedrooms.

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

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

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.-  A Service Development Plan is not required for this Licensing visit.

Kathleen Forsythe, LCSW                                                       			Date:  4-14-23
Regulatory Consultant

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

Cc:	File|


summary: Visit conducted on 1-18-23. Visit covered 20 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                                Program -Woodside Circle, Woodbury, CT

TIME OF VISIT (FROM - TO):       11:45a-2:00p          		DATE: 1-18-23

 AGENCY PERSONNEL WHO PARTICIPATED:

                                        Job Titles:

Clinical Director
Director of Operations
Clients (3)
APRN

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

?	A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included:
•	Census = 11
•	Average length of stay
•	Discharge and admission scheduled this date
•	Client incidents for the past quarter
•	No staff vacancies
•	Staff/client supervision ratios
•	Clinical team
•	Weather-related power outage in December; Generator activated
•	Education programming for residents
•	Family visits
•	Holiday activities; On-campus recreation/leisure activities
•	New gymnasium/school building under construction
•	APRN serving as program Nursing Director
•	One agency vehicle shared with another program on campus
•	Menu planning
•	Laundry schedule
•	Search policy
•	Headcount policy

?	Milieu Observation: lunch, free time, basketball game

?	Physical Plant tour of first and second floors; numerous beds unmade; graffiti observed on dining tables and door in a client bedroom.

?	Client interviews: Positive feedback from residents interviewed on all aspects of the program.

Corrective Actions implemented as a result of previous visit:
•	A service development plan was submitted to DCF by Turnbridge Woodside Circle program following a December 2022 Licensing review that addressed regulatory citations in relation to personnel files. The plan was accepted by the Department.

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

Kathleen Forsythe, LCSW                                     			Date:  1-19-23
Regulatory Consultant

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

Cc:	Executive Vice President
    	File|


summary: Visit conducted on 12-12-22. Found 3 compliance issues.

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

                                            Field Visit Reporting Form

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

NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Residential Treatment Program -Woodside Circle, Woodbury, CT

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

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Titles:
Executive Vice President

List of Areas / Topics covered during visit:   This was a scheduled semiannual personnel file review of staff hired since July 2022. The review was conducted remotely. Four personnel files were reviewed.

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

Areas of regulatory non-compliance identified during this visit:
17a-145-64	Personnel Policies and Procedures.
•	One personnel file (CH) did not contain evidence of the employee receiving a physical exam immediately prior to assuming assigned duties.
•	One personnel file (JM) contained evidence of a physical exam obtained 7.5 months prior to hire rather than immediately prior to assuming assigned duties.

Please submit a service development 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: 12-14-22
Regulatory Consultant

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

Cc:	Executive Vice President
    		File|

description: 64 Personnel Policies and Procedures.

visit_time: morning


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

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

                                                   Field Visit Reporting Form

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

NAME OF FACILITY / PROGRAM: CT Clinical Services d/b/a Turnbridge - Woodside Circle, Woodbury RTC Program

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

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

List of Areas / Topics covered during visit:  This was a scheduled quarterly Licensing visit to tour the physical plant, obtain an update on the program since the relicensing inspection conducted in July 2022, and to follow up on a complaint forwarded to DCF from DPH.
Discussion included:
•	Census = 11 males. The program is full.
•	Staffing: Discussed staff to client ratios, staffing schedule, staffing vacancies (none), client supervision procedures including bed checks, staff stations on the overnight shift, camera monitoring, 24-hour nursing coverage. Clinical staff include four therapists, a Clinical Director, and a discharge planner.
•	Program: Discussed the client daily schedule/routine. Discussed with program management client incidents since the last Licensing visit which included eight incidents of elopement, five incidents of police involvement, and seven incidents of seeking medical care in the community.
•	Discussed complaint filed with DPH from a former resident's family, which was forwarded to the DCF Licensing unit on 10-25-22.
•	Reviewed recreation schedules for August 2022 through October 2022. Staff reported recreation activities are all conducted on campus. In addition to physical daily recreation/leisure activities with an emphasis on team building (i.e., lawn games, kickball, whiffle ball, flag football, basketball, soccer, hiking, ROPES course, circuit training, swimming, etc.), special events held on site this summer included a video game truck, laser tag company, dunk tank, scavenger hunt, and outdoor movie screening.
•	Reviewed group therapy schedule. Staff reported that group therapy is held minimally four times per week and includes CBT, DBT, ACT, etc. Family therapy and individual therapy sessions are held weekly.
•	Reviewed program intake paperwork packet.
•	Case record review of former resident involved in complaint to DPH will be conducted by DCF Licensing.
•	Discussed with program management staff client use of telephone, search procedures, and client grievance procedures.
•	Client interviews were conducted.
•	Food Services: Food storage was discussed. The current 6-week menu cycle was reviewed. Discussion on menu approval process. Client interviews included discussion of food served.
•	Physical plant tour: All areas of the Woodside Circle home appeared clean, organized, attractive and decorated for the season. All bedrooms contain televisions. The outdoor heated swimming pool was observed covered for the winter and staff reported that the pool closed for the season the day before this visit. Discussed enhancing infection control procedures in shared bathrooms by storing personal objects outside of shower stalls. Breakaway closet rods are scheduled for installation. Discussed enhancing client privacy in a bedroom that contains two private bathrooms, one of which is utilized by clients from another bedroom. Small repairs to walls in some areas need painting. Personnel and equipment from a construction company were observed on the campus and staff reported that Turnbridge is building a fitness center with office space.
•	Milieu observation included lunch, fitness, academic time, basketball, and hiking.

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

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

 Kathleen Forsythe, LCSW                                                     			Date: 10-31-22
Regulatory Consultant

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


raw_content:
July 25, 2022

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

Re: Turnbridge Woodside Circle, Woodbury Boys group home
License #: CCF/GH #169
Regulatory Consultants: Kathleen Forsythe & Terri Bohara

Dear Dr. Cutter,

On July 19-20, 2022, a biennial re-licensing inspection was conducted for the Turnbridge boys group home, located at 15 Woodside Circle, Woodbury, CT. This inspection was conducted to determine the compliance of this program with the Regulations of the Connecticut Department of Children and Families Operation of Child-Caring Agencies and Facilities Regulations 17a-145-48 through 17a-145-124.

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

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

The areas of regulatory noncompliance are as follows:

17a-145-64	Personnel Policies and Procedures.
A review of documentation in ten (10) personnel files identified the following deficiencies:
•	Nine files did not contain evidence that the employee received a physical examination immediately prior to assuming duties (TrG, TeG, NG, AH, CK, DL, FM, SS, SA,).
•	One file contained evidence of a physical examination that was obtained eleven months after the hire date rather than immediately prior to hire (KM).
•	One file contained evidence of TB testing results that were obtained eleven months after the hire date rather than immediately prior to hire (KM).
•	Evidence of current CPR training was missing in two files (NG, CK).

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

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

17a-145-75	Health and Medical Treatment. Administration of First Aid. Prescription Medication. Administration of Medicine or Treatment. Written Records. Storage of Drugs, medicines, and Instruments. Sick Room, Telephone.              17a-6(g)-15(a-g) DCF Medication Administration.
d) Based on a DCF nursing review, it was determined that:
•	the facility failed to provide quarterly training to all medication certified staff
•	the facility failed to provide annual skills checks for two medication certified staff members (JB, SA).
f) Medication cabinets were found to contain internal and external medications stored together rather than separately.

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

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

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

17a-145-93	Medical, Dental, Nursing Care.
Based on a DCF nursing review, it was determined that one client record (EJ) did not contain evidence of an immunization record, as well as the results of a dental hygiene exam.

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

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

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

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

Sincerely,

Kathleen Forsythe
_________________________
Kathleen Forsythe, LCSW
Regulatory Consultant

Cc: Executive Vice President|


summary: Visit conducted on 2-19-26. No compliance issues identified. Implemented 1 corrective actions.

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

                                       Field Visit Reporting Form

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

NAME OF FACILITY/PROGRAM: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:30am-1:00pm                       DATE:    2-19-26

 AGENCY PERSONNEL WHO PARTICIPATED:
Sr. Operations Manager
Clinical Director
Client (1)

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

A meeting was held with management. The following topics were discussed:
•	Census: 7 females; program is full.
•	Staff vacancies: none.
•	Incidents from previous quarter.
•	Referral trends.
•	Holiday activities.
•	Client supervision; documentation.
•	Procedures implemented for recent large snowstorm; numerous extra staff from all departments remained on campus during storm.
•	Age waivers.
•	Biennial relicensing inspection scheduled for June 2026.

Physical Plant inspection:
•	All areas appeared very clean and organized.
Exterior entrance ramp in degraded condition; to be addressed in the spring.

Milieu Observation:
•	Female clients attending group therapy in main house on campus.
•	Numerous staff on duty in identified areas in main house.
•	Kitchen staff completing lunch prep; two nurses in nursing office.
•	Fire system inspection company on site conducting routine annual service.
•	Interview with one female client: Reported high praise for the program, citing treatment, compassionate staff and Management as high points.

Corrective Actions implemented as a result of previous visit: A Regulation Compliance Plan was submitted by the program and accepted by the Department following a personnel file review in December 2025.

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

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

Kathleen Forsythe, LCSW			                             Date: 2-20-26
Regulatory Consultant

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

Cc: 	File
      Sr. Operations Manager
      Clinical Director|

personnel:
Clinical Director
Client (1)


summary: Visit conducted on 12-15-25. Visit covered 1 main areas/topics. Found 4 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       9:00am-10:30am                       DATE: 12-15-25

 AGENCY PERSONNEL WHO PARTICIPATED:
•	President

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review. Four (4) personnel files of recently hired staff were reviewed. Files are well organized. 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-131. Cardiopulmonary resuscitation training required for persons who directly supervise children.
•	Evidence of current CPR certification was not found in three files (AH, AJ, ZA).

17a-151. Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
•	Evidence of a background check of the child abuse and neglect registry in any state in which such person or individual resided in the preceding five years was not found for Tennessee and Arizona in one file (AJ) and Pennsylvania in one file (ZA).

46a-154. Internal monitoring, training and development of policies and procedures required and subject to state agency inspection.
•	Evidence of restraint training provided by the facility was not found in three files (AH, AA, ZA).

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

Kathleen Forsythe, LCSW			                             Date:  12-22-25
Regulatory Consultant

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

Cc: 	File|


summary: Visit conducted on 11-13-25. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury,   CT

TIME OF VISIT (FROM - TO):       11:30pm-1:00pm                       DATE:    11-13-25

 AGENCY PERSONNEL WHO PARTICIPATED:
Sr. Operations Manager
Clinical Director
Client (1)

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

A meeting was held with management. The following topics were discussed:
•	Census: 7 females; program is full.
•	Staff vacancies: one 3rd shift part-time slot.
•	Incident data for the quarter.
•	Recreation activities: Halloween celebration, mobile petting zoo, ice cream truck, laser tag on campus, UFC watching event, ROPES course; heated pool now closed for the season.
•	Staff supervision stations; security checks, headcounts; security footage audit procedures.
•	Planned Thanksgiving celebration with families.
•	Christmas trees (artificial only).
•	Program schedule with another house on campus; genders dine, attend therapy and education time separately.

Physical Plant inspection:
•	All areas appeared clean and organized.
•	Two new side chairs in living room and new fire pit on outdoor patio.
•	Mold in tile grout in first floor bathroom to be addressed.
•	Large number of packaged snacks observed in one bedroom.
•	Evidence of wall repairs in some bedrooms waiting to be painted.
•	Surfaces on bedroom dresser tops in need of refinishing.
•	Cement on exterior entrance ramp walkway remains degraded - discussed plan to address.

Milieu Observation:
•	Female clients attending group therapy in main house on campus.
•	Brief interview with one female client.

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

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

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

Kathleen Forsythe, LCSW			                             Date:  11-17-255
Regulatory Consultant

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

Cc: 	File
      Sr. Operations Manager
      Clinical Director|


summary: Visit conducted on 8-7-25. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment
                                                                                Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       12:30p-2:00pm                       DATE:    8-7-25

 AGENCY PERSONNEL WHO PARTICIPATED:
Sr. Clinical Director
Sr. Operations Manager
Clinical Director
Clients (5)

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

A meeting was held with management. The following topics were discussed:
•	Census= 7; program is full.
•	Staff vacancies: One therapist (shared with boys' program); position is advertised and case load coverage provided by two Clinical Resident Liaisons. Two clinical interns and one psychiatric fellow starting for Fall semester.
•	Incidents: One incident called into Careline - not accepted for investigation.
•	Programmatic changes: Effective last week, girls eat breakfast in the house rather than the dining area in the main house on campus. Girls eat lunch and dinner in a separate dining room at main house.
•	Recent staff training on expectations, staff stations, client supervision.
•	Summer recreation.
•	New Suggestion Box for client use.
•	Swimming Pool: swim tests for all clients; neon wrists bands worn in pool to signify passing swim tests; separate swim sessions for male and female clients.

Physical Plant inspection:
•	All areas appeared very clean and organized.
•	Evidence of wall repair in second floor bedroom waiting to be painted.
•	Sink screens missing in 1st and 2nd  floor bathrooms.
•	Campus grounds are beautifully landscaped and maintained.
•	New cushions on furniture in pool area; new outdoor umbrellas.
•	Surfaces on bedroom dresser tops in need of refinishing.
•	Breakfast and snack food observed stored in house kitchen.
•	Discussion re: shower loofahs to be stored in hygiene baskets rather than in the shower.
•	Discussed possible installation of security camera in basement to capture washer/dryer area.
•	Cement on exterior entrance ramp walkway is degraded.

Milieu Observation:
•	Observed female and male clients eating lunch at the main house.
•	Discussed menus with Kitchen staff.
•	Sampled lunch served.
•	Interviews with five female clients, all of whom report high satisfaction with the program, treatment, staff interactions, food served, etc. Feedback shared with Management.
•	Suggestions for improvement solicited and relayed to Management.

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

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

Please submit a Licensing Regulation Compliance Plan (RCP) to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Licensing Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. - No RCP 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: 	File
      Sr. Operations Manager
      Clinical Directors|


summary: Visit conducted on 7-7-25. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       1:30m-4:30pm                       DATE:    7-7-25

 AGENCY PERSONNEL WHO PARTICIPATED:
•	CEO

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review for employees hired since November 2024.

Eight (8) personnel files were reviewed. Files are extremely well organized. 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 Licensing Regulation Compliance Plan (RCP) to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The Licensing Regulation Compliance Plan must be submitted to the attention of the undersigned at the address listed above. - No RCP is required following this Licensing visit.

Kathleen Forsythe, LCSW			                             Date:  7-8-25
Regulatory Consultant

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

Cc: 	File
      Sr. Operations Manager|


summary: Visit conducted on 5-21-25. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment
                                                                                Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       9:30am - 12:00pm                     DATE: 5-21-25

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Asst. Clinical Director
•	Support Staff (2)
•	Kitchen Staff.
•	Nursing Staff (4)

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

A meeting was held with the Senior Operations Manager, Asst. Clinical Director and the Clinical Director. Topics discussed included:
•	Census: 7 females. The program is full.
•	Average length of stay.
•	Staffing: 2 full time float position vacancies shared with another program on campus; new discharge planner hired; new Assistant Clinical Director, new Director of Nursing.
•	Incidents in the past quarter: two AWOL's; three clients send to hospital for psych evaluation.
•	Recreation: Special activities, Yoga on Sundays, Ropes course, petting zoo, ice cream truck.
•	Educational Services: Now scheduled seven days per week.
•	Increase in clinical evening hours on campus.
•	Female clients continue to attend group and individual therapy sessions, as well as meals in the main house on campus.
•	Boundary contracts.
•	Nursing services for Washington Rd. and Woodside Circle homes:  New Director of Nursing; Five (5) new nurses hired; APRN now splits time between Woodbury & Killingworth campuses; increase in medical staff has led to decrease in hospital visits.
•	Performance improvement.

Milieu:
•	Lunch prep observed in main house on campus.
•	Female clients observed attending group therapy in main house on campus.
•	Brief interviews with support staff, Cook, Director of Nursing, and staff nurses.

Physical Plant: Staff facilitated a tour of the physical plant interior.
•	All areas appeared very clean and organized.
•	Bathroom sinks do not contain stoppers or screens.
•	Multiple loofahs and hygiene products hanging in first floor bathroom shower, along with numerous pairs of shoes.
•	New fire pit on patio - discussed fire safety equipment availability.

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

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

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

Kathleen Forsythe, LCSW			                             Date:  5-21-25
Regulatory Consultant

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

Cc: 	File
      Operations Manager
      Clinical Director|


summary: Visit conducted on 2-10-25. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment
                                                                                Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       11:30am-12:30pm                     DATE: 2-10-25

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Kitchen Staff.
•	Nurse

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

A meeting was held with the Senior Operations Manager. Topics discussed included:
•	Census: 7 females. The program is full.
•	Staffing: No staff vacancies.
•	No significant events in the past quarter.
•	Recreation activities.
•	Female clients continue to attend group and individual therapy sessions, and meals in the main house on campus.

Milieu:
•	Lunch prep observed in main house on campus.
•	Females observed attending group therapy in main house on campus; staff seated outside group room.
•	One female client refused to attend group, was observed supervised by staff in small dining room in main house.

Physical Plant: Staff facilitated a tour of the physical plant interior.
•	Roadways on campus cleared of snow from weekend storm.
•	Front walkway contains snow - corrected.
•	Dirty dishes were observed piled in the kitchen sink.
•	Kitchen sink reportedly has a leak; water was turned off. Work order already submitted.
•	Livingroom contained empty water bottles, food wrappers related to a Superbowl party the night before.
•	Two housekeeping staff observed cleaning first floor bathroom and common areas.
•	Bedrooms were organized with beds made.
•	Painting equipment and ladder observed in a second-floor bedroom; walls freshly painted.
•	Second floor bathroom contains a cracked door and broken doorframe; replacement parts on site to be installed.
•	Package of moldy bread rolls observed in kitchen cabinet - corrected.
•	Packaged snack food observed in some bedrooms.
•	Bathroom sinks do not contain stoppers or screens.
•	Multiple loofahs and hygiene products hanging in second floor shower.
•	Slight corrosion noted on metal surfaces in second-floor bathroom.

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

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

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

Kathleen Forsythe, LCSW			                             Date:  2-11-25
Regulatory Consultant

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

personnel:
•	Kitchen Staff.
•	Nurse


summary: Visit conducted on 12-10-24. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       afternoon               DATE: 12-10-24

 AGENCY PERSONNEL WHO PARTICIPATED:
CEO

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review. Five personnel files were review. Files are well organized.
•	The CPR certification for one nurse (MI) is expired.

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

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

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

Kathleen Forsythe, LCSW                                  			Date: 12-11-24
Regulatory Consultant

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

visit_time: afternoon


summary: Visit conducted on 11-14-24. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:00am-12:35pm               DATE: 11-14-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Director of Nursing

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

A meeting was held with the Clinical Director and Senior Operations Manager. Topics discussed included:
•	Washington Road house converted to serving female population earlier this month; amended child caring facility license was issued.
•	Census: 7 females. The program is full.
•	Staffing: One Clinical Liaison vacancy; Maintenance person hired for interior painting; female staff hired in anticipation of program switch to a female population.
•	Client grievance procedure.
•	Fire drills.
•	No significant events.
•	Revamped clinical curriculum; coping skills group added; females residents do not attend group therapy sessions with male residents.
•	Brief loss of power on campus earlier this week - automatic generator activated.
•	Recreation activities.
•	Semiannual personnel file review to be conducted next month.

Milieu:
•	Lunch prep observed.
•	Females observed attending group therapy in main house on campus.

Physical Plant:
•	Staff facilitated a tour of the physical plant interior.
•	All areas of the Washington Road house appeared very clean and organized.
•	Ceiling vents throughout house cleaned on this date.
•	New wall décor installed; new dining and coffee tables.
•	Missing sink drains in bathrooms to be addressed.
•	Campus is beautifully landscaped.

Nursing:
•	Brief interview with APRN/Director of Nursing and a registered nurse in the main house on campus..
•	Director of Nursing now qualified to administer sublocade.
•	APRN medication dispensing.
•	DCF nursing orientation completed since last Licensing visit.
•	Nursing coverage 24/7 available on campus.
•	Storage and destruction process for unused controlled medication.
•	Medication refrigerator.

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

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

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

Kathleen Forsythe, LCSW                               			Date: 11-19-24
Regulatory Consultant

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


summary: Visit conducted on 8-7-24. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       10:15am-1:00pm               DATE: 8-7-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Clients
•	Kitchen Staff
•	Education Coordinator
•	Director of Nursing

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

A meeting was held with the Clinical Director. Topics discussed included:
•	Census: 7. The program is full.
•	Staffing: There are no staff vacancies. Program added several positions this year, shared with Woodside Circle program (Care Team Director, Discharge Planner, Clinical Liaison for after-hours).
•	No significant incidents during the quarter involving clients in this program.
•	Summer activity schedule; special events
•	New Director of Nursing joined the meeting. Discussed aspects of DCF Nursing Standards, Medication Administration Guidelines and available DCF Nursing Orientation.
Milieu:
•	Brief interview with Kitchen staff at Woodside program; lunch prep observed.
•	Brief interviews conducted with three clients who reported satisfaction with the program, continued positive praise for food services, and helpfulness of staff. No safety issues reported when asked.

Physical Plant: Senior Operations Director facilitated a tour of the physical plant.
•	All areas of the Washington Rd. house and Education/Gym building appeared very clean and organized.
•	Discussion on areas in need of repainting (window trim, bedroom door, two dressers.)

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

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

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

Kathleen Forsythe, LCSW                                 			Date: 8-8-24
Regulatory Consultant

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

Cc: 	File
      Operations Manager
      Clinical Director|


raw_content:
June 10, 2024

Mr. Brett Tiberio
President
CT Clinical Services, Inc. d/b/a Turnbridge
189 Orange Street
New Haven, CT  06510

Re: License # CCF/RTC 170

Dear Mr. Tiberio,

A biennial relicensing inspection was conducted for the Turnbridge Washington Rd. adolescent male residential treatment program June 4-6, 2024, which included a nursing review by a DCF Nurse Consultant.

It was determined that all areas of the program are in compliance with the DCF Regulations for the Operation of Child Caring Agencies and Facilities, as well as the DCF Nursing Standards.

As a result, the enclosed license is issued effective 8-24-24, and is valid for a period of twenty-four months.

I thank you and your staff for the cooperation extended to me during the relicensing process. Should you have any questions, please do not hesitate to contact me at (860) 937-7551.

Sincerely,

Kathleen Forsythe, LCSW
DCF Regulatory Consultant
Dept. of Children and Families
Licensing Unit
505 Hudson Street
Hartford, CT   06106
C: 860-937-7551

Cc: File|


summary: Visit conducted on 5-23-24. 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: CT Clinical Services d/b/a Turnbridge Washington Road Residential Treatment Program, Woodbury, CT

 TIME OF VISIT (FROM - TO):       1:00pm -2:45pm               DATE: 5-23-24

 AGENCY PERSONNEL WHO PARTICIPATED:
•	Sr. Operations Manager
•	Clinical Director
•	Clients
•	Kitchen Staff
•	Research Assistant
•	Chief Clinical Officer
•	Wellness Coordinator
•	Direct Care Staff
•	Care Team Coordinator.

List of Areas / Topics covered during visit:  This was a scheduled Licensing site visit for the biennial relicensing inspection scheduled for early June 2024.

A meeting was held with the Senior Operations Manager and the Clinical Director. Topics discussed included:
•	Census: 7. The program is full.
•	Staff vacancies: 0
•	No significant incidents during the quarter involving clients in this program.
•	Clients utilize the heated swimming pool at Woodside; six certified Lifeguards on staff; pool company conducted inspection; lifeguard attire; swimming times scheduled minimally three times per week on second shift and weekends; pool rules; client swim tests; need for increased first aid supplies and biohazard spill kit at pool.
•	CARF triennial survey during the past quarter -  successful 3-year accreditation period awarded.
•	Fire drill evacuation reports; frequency; review of reports for the licensed period completed.
•	Records review for relicensing inspection in June; nursing review, exit meeting offered.

Milieu:
•	Kitchen staff interviewed at Woodside program.
•	Clients eat all meals at Woodside Circle house.
•	Snacks available at Washington Rd. house.
•	Brief interviews conducted with several clients. Clients were polite and well-mannered. All reported satisfaction with the program, positive praise for the food served and helpfulness of staff. No safety issues reported when asked.

Physical Plant: Staff facilitated a tour of the physical plant.
•	All areas of the house appeared very clean and organized.
•	The grounds and landscaping are exceptional.

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

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

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

Kathleen Forsythe, LCSW                                   			Date: 6-3-24
Regulatory Consultant

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


summary: Visit conducted on 2-15-24. 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:  CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                                Program -Washington Rd., Woodbury, CT

TIME OF VISIT (FROM - TO):       10:30pm-1:20pm              DATE: 2-15-24

AGENCY PERSONNEL WHO PARTICIPATED:
•	Operations Manager
•	Clinical Director

List of Areas / Topics covered during visit:  This was an unannounced quarterly Licensing visit to obtain an update on the program and to tour the physical plant.
A meeting was held with the Operations Manager and the Clinical Director. Topics discussed included:
•	Census=7. Program is full; waiting list.
•	Staffing: One full time floater position vacancy; new Wellness/Recreation Coordinator hired; New Resident Liaison/case manager added on second shift.
•	Three EMS calls since last Licensing visit.
•	Recent holiday activities.
•	Winter storm preparedness.
•	CARF triennial survey held last week.
•	Daily program schedule, fitness activities, educational programming.
•	DCF relicensing inspection scheduled for June 2024.
•	New vehicle purchased to share with another program on campus.
•	Breakfast served in the house; dinner and lunch served in another program on campus.
•	Residents observed during program break prior to lunch.

Staff facilitated a tour of the physical plant.
•	All areas appeared generally clean and organized.
•	Evidence of recent repairs to wall damage in bedrooms and bathroom.
•	Graffiti present on bedroom furniture in one room.
•	Basement fireplace ash receptacle to be emptied.
•	Staff supervision stations.
•	Storage of hygiene products.
•	Discussion on alternative materials for interior walls.

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

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

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

Kathleen Forsythe, LCSW                                     			Date: 2-16-24
Regulatory Consultant

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


summary: Visit conducted on 12-7-23. Visit covered 1 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 - REVISED 12-13-23

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

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

TIME OF VISIT (FROM - TO):       10:30a-12:00pm              DATE: 12-7-23

AGENCY PERSONNEL WHO PARTICIPATED:
•	HR Department
•	Executive Director

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review conducted remotely.
•	Three personnel files were reviewed of staff hired since July 2023.

Corrective Actions implemented as a result of previous visit: A service development plan was submitted to the Department following an October 2023 Licensing visit. The SDP was accepted.

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 for this Licensing visit.

Kathleen Forsythe, LCSW                            			Date: 12-13-23
Regulatory Consultant

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


summary: Visit conducted on 10-5-23. Visit covered 15 main areas/topics. Found 4 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                    Program - Washington Road, Woodbury, CT

TIME OF VISIT (FROM - TO):      12:15pm  - 1:15pm       		DATE: 10-5-23

AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Clinical Director
•	Operations Manager
•	Clients
•	Chef
•	APRN & RN
•	Shift Supervisor
•	Educational Coordinator
•	Education Paraprofessional
•	Therapists

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

?	A meeting was held with the Operations Manager and the Clinical Program Director. Topics discussed included:
•	Census = 6 with one vacancy. An admission is scheduled on this date.
•	Staff vacancies: Half-time Ropes Course Coordinator.
•	Emergency planning procedures for winter weather.
•	Review of incidents and emergency calls since last Licensing visit.
•	DCF Monthly restraint/seclusion reporting requirement.
•	New weekday program schedule in new academic/fitness building.
•	Heated swimming pool repair during the summer; pool at Woodside Circle is scheduled to close mid-October.
•	Wildlife.
•	Visitation; Holiday family events

?	Milieu Observation: Lunch prep, group therapy, free time in the Woodside Circle residence. Group interviews with residents. Positive feedback from residents interviewed on the program.

?	Brief meeting with APRN re: suboxone.

?	Physical Plant tour: Management facilitated a tour of the physical plant and the new academic/fitness building. See Areas of Regulatory Non-compliance below.
•	All areas appeared clean and organized.
•	New large leather couch in living room.
•	Television is slated for wall mounting.
•	New refrigerator in kitchen.

Corrective Actions implemented as a result of previous visit: A service development plan was submitted to DCF by the Turnbridge Washington Road program following a July 2023 Licensing visit that addressed regulatory citations related to personnel files. The plan was accepted by the Department.

Areas of regulatory non-compliance identified during this visit:
17-145-73	Sleeping Accommodations.
•	One bedroom door is broken.

17a-145-74	Lavatory Facilities.
•	Second floor bathroom contains a hole in the wall, unpainted wall repairs.
•	One of the double sinks in second floor bathroom is clogged and does not have hot water.

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

Kathleen Forsythe, LCSW                                   			Date:  10-10-23
Regulatory Consultant

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

Cc:	File
	Clinical Program Director
	Operations Manager|

description: 73 Sleeping Accommodations.


summary: Visit conducted on 7-18-23. 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:  CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                           Program -Washington Rd., Woodbury, CT

TIME OF VISIT (FROM - TO):       12:00pm-1:00pm              DATE: 7-18-23

 AGENCY PERSONNEL WHO PARTICIPATED:
Job Titles:
•	Operations Director
•	Clinical Director
•	Chef
•	Clients

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

A meeting was held with the Clinical Director and Director of Operations. Topics discussed included:
•	Census: 7 males. Program is full.
•	Staffing vacancies: 0.
•	Family visitation schedule on Tuesday and Thursdays.
•	Client incidents during the quarter.
•	Recreation: On campus activities, swimming pool, ROPES course.
•	New building on campus scheduled to open next week. Contains education rooms, gym, and offices.
•	Review of Lifeguard certifications for six (6) Lifeguards on Turnbridge staff.
•	Client search and drug testing procedures.
•	Laundry procedures.
•	Client intake procedures and physical exams; waitlist, average length of stay
•	Staff/Client ratio during visit: 1:3
•	One agency vehicle available shared with another program on campus.
•	Storage of linens in basement.
•	Client haircut procedures.

Physical Plant: Staff facilitated a tour of the physical plant.
•	All areas appeared generally clean and organized. Home is beautifully decorated.
•	Address bird droppings on front porch and damage to couch.
•	Fire safety protocol discussed for outdoor firepit.
•	Food storage.

Milieu Observation: Clients from Washington Road home attend day programming at Turnbridge program at Woodside Circle on campus. Observation included group therapy; break time; lunch time; new admission tour by peer and staff.

Client Interviews: Two clients were interviewed. Clients report program is helpful.

Semiannual Personnel File Review: A personnel file review was conducted prior to the visit. 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:

•	Five personnel files were reviewed for the home at Washington Road. The following deficiencies were noted:

17a-151. Investigation. Issuance of license or provisional license. Revocation, suspension or limitation of license. Appeal.
-	Evidence was not found in three personnel files (PM, KM, TD) of a completed check of the child abuse and neglect registry in any state in which such person or individual resided in the preceding five years.

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

Kathleen Forsythe, LCSW                                          			Date: 7-19-23
Regulatory Consultant

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


summary: Visit conducted on 4-13-23. Visit covered 10 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: CT Clinical Services d/b/a Turnbridge Residential Treatment
                                                                         Program -Washington Rd., Woodbury, CT

TIME OF VISIT (FROM - TO):       1:00pm-2:30pm               		DATE: 4-13-23

 AGENCY PERSONNEL WHO PARTICIPATED:
                                        Job Titles:

Clinical Director
Director of Operations
Client (1)
Director of Culinary Services

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

?	A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included:
•	Census = 7 males - Program is full.
•	No nursing or direct care staff vacancies; additional Educational Coordinator recently hired
•	Behavior management systems; reward system
•	Lifeguards, pool safety equipment, client swim tests
•	New gymnasium/school building on campus -  construction to be completed next month
•	Case record review conducted remotely on 4-12-23
•	Swimming pool company observed onsite during visit to inspect the pool at Woodside Circle house on campus to prepare for seasonal opening
•	ROPES course, recreation activities

?	Meeting held with Culinary Services Director. Topics discussed: weekly menu cycle and approval, food allergy accommodations, food purchase and storage, soliciting client input on menus.

?	Milieu Observation: Lunch prep, lunch and interview with one client - Positive feedback from resident re: physical plant, staff, clinical services, food, recreation.

?	Physical Plant tour: Graffiti and stains observed on walls in one client bedroom; recent repair on bedroom door frame, bird droppings at two exterior porch lights, loose board on porch.

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

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

Please submit a service development plan to address the above referenced areas of non-compliance within 30 days of receipt of this report.  The service development plan must be submitted to the attention of the undersigned at the address listed above.-  A Service Development Plan is not required for this Licensing visit.

Kathleen Forsythe, LCSW                                  			Date:  4-14-23
Regulatory Consultant

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

Cc:	File|


summary: Visit conducted on 1-18-23. 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: CT Clinical Services d/b/a Turnbridge - Residential Treatment
Program - Washington Rd., Woodbury, CT

 TIME OF VISIT (FROM - TO):       11:45am-2:00pm           			DATE:  1-18-23

 AGENCY PERSONNEL WHO PARTICIPATED:

               Job Titles:
Clinical Director
Director of Operations
Client (1)

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

	A meeting was held with the Director of Operations and the Clinical Director. Topics discussed included:
•	Census = 7
•	Average length of stay
•	Client incidents for the past quarter
•	No staff vacancies
•	Staff/client supervision ratios
•	Clinical team
•	Education programming for residents
•	Family visits
•	Holiday activities; On-campus recreation/leisure activities
•	New gymnasium/school building under construction on campus
•	APRN serving as program Nursing Director
•	One agency vehicle shared with another program on campus
•	Menu planning
•	Search policy
•	Headcount policy

	Milieu Observation: lunch, free time, basketball game with residents in Woodside and Washington programs

	Physical Plant tour of first and second floors; First floor lighting discussed.

	Client interviews: Positive feedback from resident interviewed on all aspects of the program.

Corrective Actions implemented as a result of previous visit:
•	A service development plan was submitted to DCF by Turnbridge Washington Road program following a December 2022 Licensing review that addressed regulatory citations in relation to personnel files. The plan was accepted by the Department.

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

Kathleen Forsythe, LCSW                               			Date: 1-19-23
Regulatory Consultant

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

Cc: 	Executive Vice President
	File|


summary: Visit conducted on 12-12-22. Found 3 compliance issues.

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

Field Visit Reporting Form

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

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

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

 AGENCY PERSONNEL WHO PARTICIPATED:
                           Job Titles:
Executive Vice President

List of Areas / Topics covered during visit:  This was a scheduled semiannual personnel file review of staff hired since July 2022. The review was conducted remotely. Four personnel files were reviewed.

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

Areas of regulatory non-compliance identified during this visit:

17a-145-64	Personnel Policies and Procedures.
•	One personnel file (EF) did not contain evidence of the employee receiving a physical exam immediately prior to assuming duties.

17a-145-63	Chief Administrative Officer.
•	One personnel file (HP) contained evidence that the results of a criminal history background check conducted through the CT State Police is dated after the employee's start date.

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 be submitted to the attention of the undersigned at the address listed above.

Kathleen Forsythe, LCSW                                           			Date: 12-14-22
Regulatory Consultant

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

Cc: 	Executive Vice President
	File|

description: 64 Personnel Policies and Procedures.