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).

3

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.

4

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

Data:

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.

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 1 a) 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.

6

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

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

Eileen Bo en Supervisor

7

Attachment 1

Sample Action Plan

School: __________________________________________________________________________ _

Finding:

Required Corrective A~tion:

~ctions theS~hool wiU Take to Correct Noncompliance:

Date Evidence of Correction Due to State Agency:

Staff P~rsQ"RE!$pqf'~i~l~ for EaclJ Ac;tion Step .. . .. ".

Attachment 2

Tool for School to Monitor Progress of Corrective Actions

School: __________________________________________________________________________ _

Finding:

Required Corrective Action: Barriers:

< Dat~ < I~'y v Whi~h Verifying ,< Staff Person

Specific A~ions the School will Take: A~ion Step Evidence to b~ Responsible < , Must < Be Submitted "j" to for Each

I Completed State Agency Action Step

Attachment 3

Internal Consequence Plan to Monitor Progress of Corrective Actions

School: ____________________________________________________________________________ ___

Finding:

Required Corrective Action:

Nature of Evidence to be Submitted to p~~e by

Specific Actions the School will Take: Director .,. of School Staff .,erson which Consequence if < ' ~ - - Documenting' Responsible for ~ction ~tep ~cti()n $tep is

Achievement ", . of Each 'Action must iJe not achieved b~ the Action Step Step ," completed ' due date .