THE STATE EDUCATION DEPARTMENT I THE UNIVERSITY OF THE STATE OF NEW YORK I ALBANY, NY 12234

OFFICE OF P12 eOUCA nON: Office of Spetial Education

SPECIAL EDUCATION QUALITY ASSURANCE
NONOISTRICT UNIT
89 WashillQton Avenue, Room 309 EB Albany, NY 12234
Telephone: (5181473-1185 Fax: (518)4735769
wwvv.p12.nysed.gov/specialed

1 Park Place. 3'1 Floor, Peekskill. NY 10568

Telephone: (9141940-2900 Fax: (914)4022180

November 17,2014

Mr. David Armstrong

Administrator
Lakeview. NeuroRehabilitation Center
244 Highwatch Road
Effingham, NH 03882
Dear Mr. Armstrong:
On behalf of the New York State Education Department (NYSED). the Office for
People with Developmental Disabilities (OPWDD), and the New York State Justice Center
for the Protection of People with Special Needs (Justice Center), I am writing as a follow
up to the October 22, 2014 meeting with Lakeview NeuroRehabilitation Center. The State
Agencies requested this meeting to address serious concerns as to the ability of the
program to protect the health and safety of New York State (NYS) residents placed at the
Lakeview site in New Hampshire. These are the same reoccurring issues that the Justice
Center first identified at a site visit in October 2013.
In addition, the Governor of New Hampshire's decision on September 30, 2014 to
close the program to new admissions raises our concern further about the health and
safety of NYS students entrusted to your care.
Below are corrective actions that Lakeview NeuroRehabilitation Center must take by
December 3,2014. Please label your responses to each item and submit to:

Ms. Eileen Borden

Supervisor
New York State Education Department
Office of P-12 Education: Office of Special Education
Special Education Quality Assurance
Nondistrict Unit
89 Washington Avenue, Room 309 EB
Albany, New York 12234

Mr. Brian O'Donnell

Regional Director
NYS - OPWDD, NYC
Division of Quality Im~rovement
25 Beaver Street - 4t Floor
NY, NY 10004

Mr. Randal Holloway

Unit Manager
Justice Center
Division of Oversight and Monitoring
Out-of-State Placement Unit
161 Delaware Av~nue
Albany, NY 12054

Findings (1):
Lakeview failed to report to the Justice Center both the

Lakeview failed to report an allegation of abuse to the Justice Center that

Corrective Actions (1):

a. Lakeview must demonstrate a leadership structure that addresses the Justice
Center reporting requirements satisfactorily.
b. Lakeview must provide and/or re-enforce appropriate training to staff and
administration on reporting requirements for the Justice Center, and
demonstrate that consistent and accurate reporting of incidents is taking place.
Provide the name and title of the administrator overseeing this training and
oversight of implementation of the reporting requirements.
c. In order to demonstrate adequate correction of this ongoing deficiency

d. Staffing assignments must accurately reflect supervision needs and approved

clinical interventions as identified in service and behavior plans, (number,
gender, etc.);
e. The policy must clearly articulate that standards for 1: 1 supervision prohibit
assigned staff from being made responsible for any supervision of other
individuals, or concurrent assignment to other duties, as this carries too high a
risk of interruption of the 1: 1 continuous supervision;
f. Improved methods must be delineated which ensure the transfer of supervision
to another staff, reliable means to communicate the specifics of the assignment
(such as when and where the individual may be alone and where assigned staff
must wait), including a verifiable means to show that the transfer was
acknowledged and accepted by the other staff member, "and a reliable means to
document and retain records of supervision assignment and transfers - so
accountabHity may be assured, especially if an untoward incident is found to
have occurred in the recent past;
g. Limit staffing assignment to
and
2

h. Training for all staff on revised supervision standards and documentation must
be provided in a manner that requires staff to demonstrate understanding and
competence.
Findings (2):
A recent incident where three facility nurses lacking experience at the facility
each failed ,to follow facility policies and procedures resulting in
This event appears to
reflect a critical deficiency in staff training and administrative oversight.
Your website currently lists numerous job openings for the following medical
providers at the New Hampshire site: Psychiatrist, Primary Registered Nurse,
Licensed Practical Nurses, Registered Nurse, and Licensed Nursing Assistants.
These vacancies may compromise Lakeview's ability to provide the level of
medication management and medical care needed for the New York State
residents.
Corrective Actions (2):
a. Nurse training must be competency based and nurse trainees must demonstrate
adequate knowledge of facility nursing and incident reporting policies prior to
completion of training. Provide documentation of such training and demonstrated
competence.
b. Lakeview must demonstrate improved standards and practices in nursing
supervision. The facility must address how the Director of Nursing will monitor
nursing staff documentation of medication administration, required medical tests,
and nursing communication with the pharmacy and other medical providers.
c. Provide a list of all medical positions at the Lakeview site, who currently fills the
position or if vacant, credentials of person in the position, date of hire, employee
or contractual basis, full or part-time, hours per week. job responsibilities, and
indication if on-site when working. For any position vacant. indicate how long it
has been vacant and how those responsibilities are being addressed.
Finding (3):
Many incidents received by the Justice Center and observations on site support
the finding that there are insufficient crisis response staff at the facility to safely
and effectively respond to the frequent crisis that arise.
Corrective Actions (3):
a. Conduct an assessment of the average number of calls for assistance during
each shift needed to assist with behavioral crises and elopements.
b. Identify an appropriate response time for assistance to be available in a
crisis/elopement, and
c. Demonstrate that staffing is sufficient to meet the identified prevalence of
concurrent requests for assistance (without compromiSing 1: 1 and SL 1 Visual
Supervision).

Finding (4):
The failure to fix a hole in the facility's perimeter fence in a timely manner
was known that residents where using this hole to elope into surrounding forest.
a~

demonstrates a lack of environmental protection~

, Lakeview
NeuroRehabilitation Center submitted evidence that the hole was repaired on
October 24.2014 and that bids were in process for other fence repairs.

Corrective Actions (4):

a. Provide a schedule for the other fence repairs and evidence when those repairs
are completed.
b. Include evidence of central documentation of all reports of any needed repairs
that have a potential to negatively impact the safety and security
c. Detail how facility management will effectively oversee the performance of the
staff member aSSigned to this task. ensuring items are repaired or other
environmental concerns are rectified in a timely manner.
Finding (5):
'Justice Center investigations have repeatedly found evidence that Lakeview direct
care staff. were inadequately supervised to ensure they were carrying out program
plans and supervisory assignments as required.

Corrective Actions (5):

a. Include a comprehensive plan with measurable outcomes for restructuring the
clinical and administrative supervision of direct care staff [consistent with
8 NYCRR 200.15(e)(1-7), which apply to the school facility).
b. The Lakeview's Quality Assurance/Quality Improvement Department must be
restructured to be more timely and effective. including changes to incident
management practices such as:
i.
Reporting incidents to the relevant funding agency and the Justice
Center;
ii.
Execution of safety plans and incident investig'ation; and
iii.
The development, evaluation. and enforcement of corrective actions;
c. Lakeview must review NYSED, OPWDD, and OCFS regulations on permissible
restrictive interventions and the appropriate use of restraint and seclusion.
Lakeview must submit complete Mandt manual (including updates/revisions) to
OPWDD for their assessment of the propriety of its use with any individuals that
Lakeview serves.
d. Lakeview must evaluate the documentation of ongoing supervision of service
recipients to ensure that documentation requirements do not unduly detract from
staffs ability to perform supervisory duties.
e. Provide an explanation of how the duties of the Director of Quality Improvement
are being handled as a result of the position becoming recently vacant.

In addition, provide the documentation listed below:

Organizational Structure:
Provide a list and contact information for Lakeview NeuroRehabilitation Center's
(New Hampshire site) Board of Directors. Provide minutes of the meetings held
since July 1, 2013 to the present.
Provide a list/chart of all school and residential administrators' titles, percentage
of time on site, and their duties and responsibilities in the school and residence.
Provide a list/chart of all school and residential medical staff titles, percentage of
time on site, and their duties and responsibilities for school and residence.
Provide a supervision plan for ensuring the health and safety of all students;
(e.g. levels and/or zones were discussed) in the school and residence. Include
name and title of person accountable for overseeing this plan. Provide definition
of all terms.
Behavioral Support:
Provide documentation for how Lakeview NeuroRehabilitation Center documents
emergency restraints for New York State students pursuant. to
8 NYCRR 200.22(d)(4) for the time period of July 1, 2013 - present. Include
name and title of person accountable for overseeing this plan.
Provide all school and residential incident reports for New York State students
for the time period of July 1,2013 - present.
Provide a list of all NYS students with 1: 1 aides delineated by school and/or
residence.
Provide the name and title of the person who oversees the 1: 1 aides in the
school and residence and ensuring that staff is aware of the levels of supervision
according to IEPs and Behavioral Intervention Plans (BIPs) for school and
residence.
Explain if students have separate BIPs in the school and residence or one plan.
Provide copies of all BIPs for NYS students.
Explain how Lakeview NeuroRehabilitation Center ensures that all staff are
aware of and following Behavioral Intervention Plans for New York State
students.
Define criteria for when Lakeview NeuroRehabilitation Center implements
Emergency and Safety protocols, describe the protocols, and date such
protocols were developed.
Communication:
Explain how school and residential administrators communicate and share
information. Provide the name and title of the person accountable for overseeing
this.
Describe the purpose of the Risk Management Meeting and when this was first
implemented. Explain how information is documented and shared with staff
including how changes in student and adult supervision levels are
communicated to staff.
5

..

Describe how staff communicates and shares information on a daily basis

between school and residence including the method for ensuring that this
occurs. Provide the name and title of the person accountable for overseeing this
process.
Describe the method for communicating information with New York State
Committees on Special Education and parents of New York State students.
Provide the name and title of the person accountable for overseeing this
process.

Data:

Explain the system for storing and maintaining educational paper records prior to
Lakeview NeuroRehabilitation Center fully shifting to electronic records.
Identify where all educational, medical. and incident reports are stored.
Provide elopement data for New York State students for the following school
years (minimally include name of student. date, incident. time eloped and time
found. medical intervention sought):
2012 - 2013
2013 - 2014
2014 - 2015

Describe any other new actions that Lakeview NeuroRehabilitation Center has
taken to address the issues discussed at the meeting, dates of implementation, and the
name and title of person accountable for overseeing the actions.
Enclosed are several sample templates that you may choose to follow for your
submission, due no later than December 3, 2014, or you may develop your own format
as long as the elements in the sample templates are included. Clearly label each item
using the numbering/lettering system noted above (Le .. Correction Action 1a) and the
names of the additional items (Le., Organizational Structure). In addition, you must
continue to provide OPWDD and NYSED with an acceptable plan of correction from their
May and June 2014 visits. NYSED, OPWDD, and the Justice Center will review and verify
that Lakeview NeuroRehabilitation Center has satisfactorily addressed all issues.
Pursuant to NYSED Special Education Regulation 200.7(a)(3), please be aware
that failure to provide adequate evidence of the correction of programmatic deficiencies
and violations of State and Federal law or regulations which the NYSED commissioner
believes to exist at Lakeview may lead to NYSED termination of Lakeview's private school
approval and removal from the list of private schools approved for reimbursement with
public funds. NYSED and OPWDD may require additional meetings and/or implement
enforcement actions as necessary.

If you have any questions, you may contact me at (518) 473-1185.

Eileen Bo en
Supervisor
Enclosures
c: James Delorenzo, NYSED
Jacqueline Bumba/o, NYSED
Jacqueline Harnett, NYSED
Carla Nolan, NYSED
Abiba Kindo, OPWDD
Brian O'Donnell. OPWDD
Randal Holloway, Justice Center
laura Velez, OCFS
Renee Hallock, OCFS
Marilee Nihan, New Hampshire
Santina Thibedeau, New Hampshire
Christopher Slover, lakeview
Tina Trudel, Lakeview
Amanda Goza, Lakeview
Corinne Rocco, Lakeview
Lorene Zammuto, Lakeview

Attachment 1

Sample Action Plan

School: ___________________________________________________________________________

Finding:

Required Corrective

Date Evidence of Correction

Due to State Agency:
A~tion:

~ctions theS~hool wiU Take to Correct Noncompliance:

Staff

P~rsQ"RE!$pqf'~i~l~

EaclJ Ac;tion Step

.. .

..

for

".

Attachment 2

Tool for School to Monitor Progress of Corrective Actions

School: ___________________________________________________________________________
Finding:
Required Corrective Action:
Barriers:

<

Specific

A~ions

the School will Take:

<

Dat~
Whi~h
<

I~'y

Verifying
Staff Person
Step
A~ion
Evidence to b~ Responsible
Must
Submitted
"j"
Each
to for
Be
Action Step
Completed
State Agency
<

,<

Attachment 3

Internal Consequence Plan to Monitor Progress of Corrective Actions

School: _______________________________________________________________________________
Finding:
Required Corrective Action:

Specific Actions the School will Take:

<

'

~ -

Nature of Evidence
to be Submitted to
Director .,. of School
Documenting'
Achievement ", . of
the Action Step

p~~e

Staff
.,erson
Responsible for
Each
'Action
Step
,"

by

Consequence if
$tep is
must
iJe not achieved b~
completed ' due date .

which

~ction ~tep ~cti()n