January 21, 2014

David Armstrong, RN
Administrator
Lakeview New Hampshire NeuroRehabilitation Center
244 Highwatch Road
Effingham, NH 03882
Dear Mr. Armstrong:
The New York State Justice Center for the Protection of People with Special Needs
(Justice Center) visited Lakeview New Hampshire NeuroRehabilitation Center (Lakeview)
during the week of October 20, 2013, to review the services, safety and supervision provided to
Lakeview New Hampshire residents placed or funded by New York State. Justice Center reviews
and investigations conducted at schools and facilities located outside of New York State are
carried out pursuant to the requirements of Article 11 of New York Social Services Law, Section
490(5). Justice Center investigative oversight and mandated reporter requirements are reflected
in the contracts and provider agreements that schools and facilities enter into with New York
State oversight agencies and local districts for approval of the funding for these placements.
At the close of the Justice Center visit, our staff met with your management team to share
positive impressions, concerns and preliminary recommendations. This correspondence formally
documents the concerns and recommendations shared during that meeting in order to ensure
adequate communication of Justice Center preliminary findings to both Lakeview New
Hampshire and the New York State funding agencies; and where there is agreement to provide
opportunities for Lakeview to begin correcting identified deficiencies. This does not preclude the
Justice Center from issuing a report or additional findings at a later date.
Justice Center preliminary findings and recommendations are organized into the
following seven categories: Safety, Basic Needs and Individual Rights; Personnel and Training;
Incident Management; Programming, Services and Treatment; Policies and Procedures; and
Physical Plant and Environmental Conditions.

Safety, Basic Needs and Individual Rights

In many respects, Lakeview policies and practices were appropriate to ensure the
preservation of resident civil rights and provision of basic living needs. Adequate space was
available for all necessary services and supplies were sufficient for ongoing program operations.

However, during the visit, Justice Center staff found that the safety of New York residents was
not consistently and reliably maintained due to inadequacies in facility staffing, supervision
policies, behavior management practices and incident management practices. The Justice Center
found evidence of repeated, preventable instances of potentially dangerous resident elopements,
self-injurious outbursts and aggression against peers. Justice Center recommendation to address
these deficiencies will be detailed in the sections specific to each category.

Personnel and Training

In the specific Lakeview residences serving New Yorkers, the Justice Center found
evidence of periodic staffing shortages that impeded efforts to implement prescribed behavioral
supports in a safe and effective manner. Shortages led to supervision levels being reduced from
the 1:1 staffing identified in individual behavior support plans to line-of-sight level, a substantial
diminution of supervision which significantly limits staffs ability to effectively manage
aggressive outbursts or come to the assistance of staff needing help to de-escalate a crisis.
Staffing shortages were found to be a contributing factor in several incidents of peer-on-peer
aggression, aggression against staff, dangerous aggression towards self or objects and resident
attempts to elope. Justice Center staff witnessed the facilitys inability to address two concurrent
crises during the second afternoon of our visit, when two staff members assisted in the return of a
resident who had eloped, but no one could be found shortly thereafter to help assigned staff
manage another resident who was becoming aggressive. In our interviews with staff, they
explained that most residents require 1:1 supervision and this limits the ability of staff members
to assist in a crisis. Several staff further reported that at times, they must physically intervene
with an aggressive resident without other staff assisting, even though two staff are indicated for a
safe intervention. Further, staff members noted that due to staffing shortages, requests to be
removed from 1:1 involving a resident actively targeting that staff member for aggression are
refused.
Recommendations #1: The Justice Center recommends that meaningful and substantive efforts
be undertaken to ensure that sufficient staff are on duty at Lakeview across all shifts to ensure
that the supervision levels prescribed in individual plans are reliably maintained and necessary
1:1 staffing reassignments can be accommodated. It is further recommended that the facility
administration address the evident need for sufficient trained staff to be available to promptly
respond to all crises as they occur, with the understanding that the population being served
makes it likely that multiple crises may occur at the same time. It is understood that facility
policy may have to be revised to formally require responses from otherwise occupied clinical and
administrative staff as the number of concurrent crises escalates.

Incident Management
The Justice Center is concerned that allegations of abuse and neglect involving New
Yorkers were reported to the Vulnerable Persons Central Register (VPCR) by outside parties,
rather than by Lakeview staff. Several additional potential incidents of neglect were identified by
Justice Center staff during the on-site record review, none of which had been reported to the
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VPCR, despite acknowledgement of this Justice Center requirement in a New York State Office
for People With Developmental Disabilities (OPWDD) Agreement and Statement of
Obligations which you as a Lakeview administrator signed on June 20, 2013.
In our examination of facility investigations into the above noted incidents, we found
insufficient evidence of investigative activities to support the stated determination(s). There was
no evidence of interviews with residents, inclusion and review of relevant facility
documentation, assessments of staff adherence to treatment or behavior plans, or signed witness
statements from any parties. Neither was there in any instance a comprehensive investigation
report which presented in an organized manner the investigation process, relevant findings,
rationale for determinations or recommendations for needed corrective actions. Finally, no
comprehensive review and approval of the investigation was documented by a properly
constituted incident review committee.
Recommendation #2
While the Justice Center understands that New Hampshire law does not require that your
facility conduct an independent investigation into allegations of abuse, the Justice Center
recommends that Lakeview develop this capacity as a best practice, along with a comprehensive
incident review committee process, in order to ensure the safety of all service recipients and
assist in quality improvement efforts.
Recommendation #3
The Justice Center further recommends that the Lakeview administration take substantive
steps to ensure staff accountability for the appropriate required reporting of all incidents to both
internal and external parties. We expect that this will require enhancements to staff training and
ongoing quality assurance monitoring of program records to ensure compliance.

Programming, Services and Treatment

The Justice Center review included an examination of residential services, rehabilitation
programming, safety and supervision in elementary and secondary education settings, and
vocational/habilitation programming. The one concern identified related to the adequacy of
habilitation/vocational programming provided to young adults no longer attending school. In our
observations of programming and interviews with staff working in the Young Adult Program
(YAP), we learned that Wednesdays and Thursdays are the only days where structured activities
are regularly planned. Other days, residents are primarily given journaling assignments, which
did not appear to reflect the individuals developmental levels and realistic goals, as some
residents lacked skills to read and write independently, requiring staff to provide hand-over-hand
assistance. Staff report easily losing the participants attention and a lack of learning retention.
Some YAP participants lacked basic living skills, and vocational training to attain mastery in
these areas may be more developmentally appropriate, more engaging for the resident, and can
be creatively tied to a residents stated interests if the effort is put forth.

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Recommendations #4
The Justice Center recommends a review and assessment of the functional component of
the YAP and a plan of correction which ensures that vocation, pre-vocational and habilitation
activities are individually designed, provided, reviewed and modified to accurately reflect each
individuals interests, needs and current abilities.

Policies and Procedures

The Justice Center review of Lakeviews policies and procedures focused on those
related to incident management, staff training and resident supervision. In addition to
aforementioned concerns related to incident management practices, Justice Center staff were
troubled to learn that residents assigned to line-of-sight supervision had no specified staff
member assigned to maintain this continuous observation. As such, staff accountability could not
be assured. As noted previously, the reduction of supervision levels of residents normally
assigned 1:1 supervision reduced to line-of-sight based on staffing shortages only increased
Justice Center concerns. Individual plans indicated that 1:1 staffing was necessary for resident
safety and the shared staffing pattern of line-of-sight supervision (where a staff member is caring
for more than one resident) leaves other residents without continuous supervision when that staff
member is addressing the dangerous behavior of another resident.
Recommendation #5
The Justice Center recommends that Lakeview review and modify facility policy to
ensure that individuals requiring line-of-sight supervision be assigned to a specified staff
member who retains responsibility for staying within view of the individual. These assignments
should be documented, retained for a prescribed time period for potential incident management
purposes, and be developed for the documented transfer of assigned supervision between staff to
account to shift changes, breaks and other necessary staffing reassignments.

Physical Plant and Environmental Conditions

Justice Center staff were pleased to note that the grounds of Lakeview were attractively
maintained and cleanliness throughout the campus was managed by the team of staff dedicated to
that task. School programs on campus displayed developmentally appropriate materials and
student projects in a manner that complimented the work being accomplished. We also noted
ongoing renovations to the residential cabins and safety enhancements being made in response to
recent incidents. The only identified deficiencies related to environmental conditions and fire
safety in cabins Monterey 1 and 2. In these cabins, we found one extinguisher discharged and out
of place and another in a housing that could not be unlocked. These concerns were immediately
addressed by the maintenance supervisor.
We also noted some of the furniture in these cabins was in poor repair and the amount of
serviceable furniture in shared areas was not sufficient for resident needs. Finally, we
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commented that common areas and individual bedrooms lacked the attractive, personalized
decorations observed in other areas, which is believed to enhance the impression of residents and
visitors that the cabin really is serving as a home.
Recommendation #6
The Justice Center recommends that Lakeview modify start of shift maintenance checks
to ensure that all fire extinguishers are charged, in place and accessible.
Recommendation #7
The Justice Center finally recommends that Lakeview reassess furnishings and decorative
elements in cabins Monterey 1 and 2 and make necessary purchases and improvements.
The Justice Center appreciates the cooperation shown by all Lakeview staff and
administrators during our visit and hopes that these observations and recommendations offer
opportunities for positive change. We request your review of the included recommendations and
a response by February 21, 2014.

Respectfully,

Randal L. Holloway, Unit Manager

Division of Oversight and Monitoring
Out of State Placements Unit
CC:

James Delorenzo, NYSED

Megan OConnor-Hebert, NYS-OPWDD
Emily Bray, Esq., NYS-OCFS

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