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.

Page 2 of 5

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

Page 3 of 5

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.

Page 4 of 5

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

Page 5 of 5

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