Review of the State of New Hampshire?s
Oversight and Monitoring of the Services
Provided by

Lakeview Neuro-Rehabilitative Center

Prepared for Governor Hassan

Prepared by:

du Free, MP5
President

Crosswinds Consulting LLC

April 2, 2015

Table of Contents

Section I Introduction

Section II The Responsibilities ofthe DHHS

Section Licensing

Section IV Investigations of Abuse, Neglect and Exploitation
And Complaint Reviews

Section The Role ofthe Area Agencies

Section VI Summary

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Section I. Introduction

Governor Hassan became increasingly concerned about the quality of
services provided to individuals who are served by Lakeview euro-
Rehabilitative Center (LNC) as the result of a report of a death of a resident
that occurred in 2012 that was investigated by the Disabilities Rights Center
(DRC) and reported in September 2014. The findings of this investigation
highlighted numerous concerns regarding health care and assessment,
programming, staff training and consistency, staff supervision, program
monitoring and overall quality. The DRC made many substantive
recommendations including closing the LNC program in New Hampshire.

In response the Governor stopped any further admissions to Lakeview from
New Hampshire, required the health facilities licensing bureau to inform
other states of this decision, and directed a three- phase review of services at
LNC. The first phase was a licensing review completed by staff of the
Department of Health and Human Services (DHHS) that were health facilities
certification bureau staff not assigned to LNC, and an independent expert in
quality assurance and program monitoring. This was completed in November
2014 and resulted in many findings of deficiencies and a requirement for LNC
to develop and implement a Plan of Correction (POC). The second phase was
an independent review of LNC and the third phase was an independent
review of the state?s monitoring and oversight efforts. This is a report of the
third phase of the Governor?s directive to review the services provided by
LNC and the state?s oversight of these services.

Governor Hassan has asked for an independent review of the quality of the
monitoring and oversight of Lakeview euro-Rehabilitative Center (LNC) by
state agencies. These include entities within the Department of Health and
Human Services including The Bureau of Elderly and Adult Services (BEAS),
Bureau of Developmental Services and its Office of Client Legal Services
(OCLS), and the Health Facilities Licensing Bureau (HFLU). It also includes
the Area Agencies that fund service providers and provide service
coordination for individuals receiving supports and services from DHHS.
Each of these entities has some responsibility for assuring the quality of
services individuals receive and for protecting them from abuse, neglect and
exploitation.

It was important for me to talk to the many stakeholders involved with
oversight of Lakeview and review a number of relevant documents produced
by various sources in order to have a comprehensive understanding of the
requirements that are established for a facility such as Lakeview and how the
state has tried to determine if Lakeview consistently meets these
expectations. These include the rules governing the licensing of a residential
treatment and rehabilitation facility the complaint process; the
abuse and neglect investigation process; and the functions of the Area
Agencies. 1 also reviewed the Licensing Inspection Report issued by DHHS in
November 2014. I have interviewed administrative representatives from the
New Hampshire Department of Health and Human Services (DHHS) including
department leadership, complaint investigators, licensing inspectors, and
abuse /neglect investigators, and the New York State Justice Center. I also
interviewed two members of the survey team that conducted an inspection of
LNC in November 2014 at the request of Governor Hassan as the first phase
of this review.

I have talked with staff from the Disabilities Rights Center of NH, Community
Support Network, Inc., (CSNI) and Area Agencies Directors. I also interviewed
former employees of DHHS who reached out to me.

I want to thank everyone for his or her responsiveness and candor. I greatly
appreciate the coordination that Frank Nachman, Legal Counsel provided and
the numerous document he provided for me to complete a thorough review.

In general I find that the actual rules are adequate in many areas with the
significant exception of the rules that establish the basic licensing
requirements for Lakeview Neuro-Rehabilitation Center. Therules
governing the abuse and neglect investigations conducted by both Adult
Protective Services (APS) within BEAS and the complaint investigation
process conducted by OCLS have inherent weaknesses that do not allow New
Hampshire to have a comprehensive understanding of these overall concerns
for a facility such as Lakeview or to consistently determine the underlying
causes of abuse and neglect and address these systemic concerns.

Overall the rules provide reasonable standards for the development and
implementation of a service delivery system that expects the protection and

suitable care of individuals with developmental disabilities within a
community-based system of care. However these expectations are not always
applied to Lakeview and the oversight and monitoring system has
significantly failed the residents of Lakeview and their families by not
assuring them even basic protection from abuse, neglect and exploitation.
This is due to many systemic factors including a lack of sufficient resources to
effectively monitor Lakeview; a lack of coordination, cooperation and
communication among advocacy agencies, other states? monitoring divisions
and New Hampshire?s DHHS which is amplified by New Hampshire?s lack of
meaningful responsibility to protect out of state residents that reside at
Lakeview; a lack of a contract with Lakeview specifying overall programmatic
and financial accounting expectations; and a lack of administrative leadership
setting high expectations for quality monitoring of all of its facilities.

Section II. The Responsibilities of the DHHS

The responsibilities of the Department of Health and Human Services 
are addressed in RSA 171-A, 126- A, 151, and their Implementation Rules.
DHHS is responsible to ensure the health, safety and well- being of the
individuals it serves. RSA171-A: 4 require DHHS to maintain a state service
delivery system for the care, rehabilitation, treatment and training of persons
with developmental disabilities. The Commissioner is required to contract
with Area Agencies to carry out case management, service delivery and other
responsibilities at the community level (RSA 171-A: 18).

The system is to be based on full participation in the community, sharing -
ordinary places, developing meaningful relationships, and learning things
that are useful, as well as enhancing the social and economic status of
persons served (RSA 171-A). Further, the state is to make service agreements
based on the criteria of the least restrictive environment; promoting
individual health and safety; promoting individual right to freedom from
abuse, neglect and exploitation; promoting community participation; and
ensuring the right to adequate and humane rehabilitation including
medical and rehabilitation to bring about
improvement. The above is defined in 505 and RSA 171- A: 1, VI.

The oversight of the system of services involves the Health Facilities
Licensing Bureau, The Office of Client and Legal Services Bureau of
Developmental Services, Adult Protective Services of the Bureau of Elderly
and Adult Services, and the Area Agencies. In the following sections I will
brie?y summarize the responsibilities of these entities as they relate to
oversight, monitoring and investigation and note areas of shortcoming in
assuring quality and protection from harm.

Section Licensing

RSA 151:2 establish the responsibilities of the Licensing Bureau of DHHS. The
Licensing Bureau bears the responsibility to ensure facilities that provide
medical, nursing and remedial care will ensure safe and adequate treatment
of such persons in the facility. The Licensing Bureau conducts at least one
annual unannounced clinical inspection to determine if the facility is in
compliance and the facility and programs and services are appropriate to the
needs of the residents (RSA 151:6-a I). It also conducts an annual Life Safety
inspection. DHHS may suspend or revoke a facility?s license.?

The Rule governing Residential and Health Care Facilities are in Chapter
800: Residential and Health Care Facility Rules Statutory Authority.
807.01 states the purpose is to set forth the licensing requirements for
all residential treatment and rehabilitation facilities pursuant to RSA
151:2,1 Lakeview is considered a Residential Treatment and
Rehabilitation Facility (RTRF).

The rule covers a number of areas including: complaints; duties and
responsibilities of the Licensee; client admission criteria, temporary
absences, transfers and discharges; required services; medication services;
personnel; client records; food services; infection control and physical
environment. While some sections are adequate many do not include the
basic expectations that the state should place on a facility providing intensive
support and supervision to individuals with challenging needs.

The Personnel section (807.18) does not include sufficient expectations for
staff training. Areas that should be included are abuse neglect and
exploitation including reporting requirements; restraints; person-centered

planning; positive behavioral programming; the concepts of most integrated
setting and the Americans with Disability Act First Aid; and
incident reporting.

There are no standards for providing habilitative services; person-centered
planning; assessments; review of restrictive programming including the use
of medication; or staffing expectation based on the acuity of
individuals served.

The Compliant section 807.11) is a general description of the
complaint process and does not specifically mention complaints of abuse,
neglect or exploitation. Complaints are handled by OCLS and there are
separate rules governing the review of complaints. The HFLU also
investigates some complaints. However there should be specificity in the rule
given the importance of this topic and the lack of reporting and follow up that
has occurred at Lakeview.

Licensing conducts both Life Safety and Clinical Inspections of Lakeview on
an annual basis. I was provided the Life Safety Inspections for 2011, 2013,
and 2014. There was no Life Safety Inspection shared with me for 2012. The
inspection completed in 2011 was not sent to the administrator for Lakeview
until January 8, 2013. Areas of deficiency were not addressed for over a year
as a result.

I requested the summaries of the clinical inspections. I was told that they had
been completed each year but there was no report because there were no
deficiencies. This is troubling for two reasons. It is virtually impossible to
operate a program serving a multitude of individuals with hundreds of staff
implementing programs and following procedures and not experience any
deficiencies. Secondly, every inspection should result in a report even if it is a
summary of the areas that were evaluated and the positive results that
supported a finding of no deficient areas to demonstrate the validity and
transparency of the process. This should be publically available so that
participants, families and other stakeholders are fully aware of the state?s
expectation of a facility and its performance toward meeting its standards.

There are currently two Inspectors assigned in the Health Facilities Licensing
Unit to complete clinical inspections and also handle complaints for Assisted
Living Facilities and non-certified Nursing Facilities. They are also

responsible for including Lakeview. There are 1,000 facilities that are
licensed of which 400 receive annual inspections. HFLU also inspects new
facilities. There were 3.5 position assigned to these functions within the unit.
One position became vacant over the past few months and was unfunded in
the Governor?s proposed budget. The part time surveyor is on medical leave.
This is not a sufficient number of positions to complete thorough annual
inspections of over 400 facilities and addresscomplaints on a timely basis.
Clinical inspections should involve two inspectors who are onsite for 2-3
days at minimum. The team that conducted the inspection of Lakeview in
November included 4-5 surveyors who spent a few days at the facility.

The training of the surveyors is minimal at best. The Director of the Unit
reports that surveyors are trained by shadowing senior surveyors. The Unit
does not provide any formal training. Surveyors have limited opportunity to
attend workshops and have not been able to attend the National Association
for Regulatory Administrators since 2003 because of a lack of funding. The
Unit needs to develop formal training that is competency based and includes
an orientation to the Department?s mission and vision. It should also re?ect
best practices in the fields related to the areas of inspection that are being
completed. Surveyors should have a basic understanding of quality
improvement processes. Funding should be made available for surveyors to
attend national conferences in their field so they remain current in the
developments in regulatory practices and quality assurance.

1 was able to interview three individuals who worked previously for DHHS in
the Licensing Unit. They are credible individuals, two of whom remain
actively involved in the human services field in New Hampshire. They noted
differences in the organization; direction and philosophy of the different
areas of licensing noting that the survey team that inspected facilities under
Medicare was better resourced and trained than the surveyors who inspected
the They reported that oversight was less diligent and the standards
were less clear for the and non-certified NFs. They gave examples of
administrative intrusion into regulatory findings and reports. At one facility
there were 75 deficiencies noted and the surveyors were only allowed to cite
32. This was determined through a review by administrators not by the
findings of the inspectors.

They reported that there have been previous times when inspections found
egregious concerns about Lakeview that may have warranted closure and no

action was taken. They report that the Licensing Unit is not held in high
regard in the community because it is not perceived to be diligent or
rigorous. They worked for the agency several years prior to the appointment
of the new Commissioner and find Commissioner Toumpas to be a "breath of
fresh air.? However their concern is that other staffs remain with the agency
who had direct or indirect relationships with Licensing and the overall
organizational approach to inspection has not changed.

I believe the administration needs to clarify its expectations of licensing and
hold the staff directly involved accountable for a thorough and rigorous
review of facilities that are trusted to serve vulnerable individuals. This
vision must be set and articulated by the senior leadership if the agency is to
achieve a cultural shift in its expectations for quality among its service
providers and its expectation for comprehensive review and accountability
among its quality review staff.

Previous and current staffs support my finding that the rules are inadequate.
The ex-employees state that the last time the rules were updated the rule
writing committee was comprised of many providers. Individuals who
rewrote the rules did not have regulatory experience or expertise. The Team
Lead for the team that inspected Lakeview in the fall of 2014 and the outside
expert who joined the team shares the perspective that the rules are
inadequate. Michael Fleming, Team Leader said he used his background and
experience surveying MA qualified nursing facilities to determine the areas of
services to inspect at Lakeview. He then anchored these expectations to the
broad but less well defined 807 rule requirements. John Martin, the current
Director of the HFLU agrees the rules are probably inadequate for a
residential treatment facility.

The Office of the Legislative Budget Assistant completed an audit of the
Health Facilities Licensing Unit for FY2012 and 2013. The report was issued
on June 2014. It found the HFLU generally efficient and effective but found it
did not complete all life safety inspections in 2012.

The OLBA made the following recommendations:
0 Revise the rules
0 Establish written policies and procedures
0 Improve the handling of complaints and ensure deadlines are met
0 Retain inspection information

0 Notify complaints .

0 Collect data to measure overall performance and effectiveness

0 Change the clinical inspection process so that site inspections are not
done at predictable time

Findings: Lakeview has been able to operate its program at an
unacceptable level in large part because the rules governing its functions
are inadequate and the inspections have not been rigorous. Additionally
there appears to be a lack of commitment to quality and thorough review
of a facility such as Lakeview by Licensing Unit. Lakeview had no
clinical deficiencies for four years including early 2014.

During this time the Area Agencies were becoming increasingly concerned
with services and Lakeview and began to take steps in late 2013 to
address them. One parent in particular was making her concerns known to
the Licensing Unit. The DRC of Maineconducted an investigation of
Lakeview and its concerns were public knowledge. The DRC of New
Hampshire had raised concerns prior to its report in September 2014. The
NYS Justice Center UC) conducted numerous investigations that were
shared with the HFLU. The IC directed Lakeview to conduct its own
inveStigations and improve its quality oversight because ?New
Hampshire?s oversight of Lakeview is not sufficient to ensure the safety of
service recipients placed from outside the state.? OSHA cited Lakeview for
numerous workplace concerns including workplace violence, due to
insufficient staff and poor training.

None of these rather blatant signs of organizational dysfunction prompted
any additional review by DHHS until the Governor?s directive. The issues
noted in the survey conducted in November 2014 re?ect many serious
and systemic concerns. Lakeview acknowledges in its Plan of Correction
that many of these problems are chronic. They include poor incident
reporting, inadequate staff training, and an inability to meet the levels of
supervision the individuals need on a consistent basis. Individuals and
staff have been hurt as a result. These issues were problematic for
Lakeview long before they were cited in the 11/14 Licensing Report. They
were not surfaced in any of the reviews conducted in the prior four years
by the HFLU. If they had been noted Lakeview would have either

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demonstrated its ability to correct its deficiencies and improve quality, or
the state would have known long before now that the facility did not have
the capacity to structurally improve, and been compelled to take action.
Either outcome would have resulted in a safer environment for Lakeview
residents.

Recommendations: The Rules need to be re-written to re?ect the state?s
expectations for a residential treatment facility and its commitment to
individualized services and the opportunity for community living as
expressed in RSA 171. The Licensing Unit needs to add Surveyors and
provide comprehensive competency based training. The leadership of this
area needs to demonstrate its commitment to the changes DHHS expects.

Section IV. Investigations of Abuse, Neglect and Exploitation and
Complaint Review

New Hampshire DHHS places the primary responsibility for the
investigations of abuse, neglect and exploitation of adults with the Bureau of
Elderly and Adult Services (BEAS) through the Adult Protective Services
(APS) Unit. Chapter 161-F 42-57 details these responsibilities. It defines the
responsibilities of individuals to report suspected acts of abuse, neglect, self-
neglect and exploitation or for individuals who live in a hazardous situation.
Investigations are to occur in a timely period and the findings are shared with
the Commissioner. Individuals are placed on a Registry if the allegation of
abuse, neglect or exploitation is substantiated. Providers are not allowed to
hire a prospective employee if he is on the Registry unless a waiver is-
granted. APS often co-investigates with Complaint Reviewers from the
Bureau of Developmental Services, Office of Client and Legal Services (OCLS).
APS is limited in its investigatory role. It can only investigate where there is a
named perpetrator. It can only substantiate a finding of abuse, neglect or
exploitation against an individual(s]. It does not have the authority to
substantiate abuse, neglect or exploitation if there is not an identified
perpetrator and cannot make systemic findings or recommendations. APS
investigates all allegations of adults who reside at Lakeview regardless of
their state of origin. Findings are shared with guardians and state agencies.

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The Department of Children, Youth and Families (DCYF) does investigate
allegations of abuse and neglect of children. While the law allows DCYF to
investigate abuse and neglect its own definition of neglect is limiting in that it
is defined as an act committed by a parent, guardian or custodian. DCYF does
not investigate in the educational program but only in the residential service
of a facility such as Lakeview. DCYF shares its results with Licensing although
notes not all of its recommendations are made in writing. Lakeview receives
a verbal report and does not have to respond in writing with its corrective
strategy. Guardians are informed of the finding and can request the full
report. Other states are not directly informed of the allegation or findings but
may get access to the information with a release from the guardian.

The OCLS within the BDS is responsible to respond to complaints. These
responsibilities are described in 202: Rights Protection Procedures for
Developmental Services. The Purpose of these rules is to define the
procedures for protection of the rights of persons applying for eligible for, or
receiving services from area agencies or developmental services or acquired
brain disorder programs funded through the bureau of developmental
services.

202.03 states ?a person wishing to make a complaint may make the
complaint orally or in writing to the OCLS (Office of Client and Legal Services)
or any employee of an area agency, a program, or the bureau. Any person
receiving a complaint shall forward the complaint to the OCLS.
Under 202.04 Responsibility to Complain through specifically
details the responsibilities of the AA and subcontractor program, i.e.
Lakeview. To summarize: employees of the department or an area agency
or program shall make a complaint on behalf of the individual
whenever they have reason to suspect that an individual has been subjected
to abuse, neglect, exploitation, or a rights violation by an employee of, or a
contractor, or volunteer for an area agency or program. The person
making the complaint or filing complaint shall forward complaint to OCLS. 
ASAP but not later than one business day following receipt, OCLS shall submit
complaint to a Complaint Investigator and inform the Executive Director of
the appropriate AA that complaint was filed. Complaint Investigator shall
report a complaint of abuse, neglect, or exploitation of an individual or other
person to the bureau of elderly and adult services or division for
children, youth and families (DCYF), as appropriate.

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 202.07[a) stipulates that OCLS will have three (3) persons designated
as complaint investigators, or more if needed to carry out all the duties of the
complaint investigator within the timelines required by 202. Section
states the investigator shall attempt to resolve the complaint within
fifteen (15) days.

Priority of complaints is covered in ?complaints involving abuse, neglect,
or exploitation shall be investigated prior to any other complaints. Such other
complaints shall be investigated in the order they were received.

Section details the eight (8) categories that must be included in the
investigators report for OCLS to review. Section (0) designates who gets the
final report and the timelines. It states,? following OCLS review to determine
that the elements in above have been addressed and within 15
days of the filing of the complaint, the complaint investigator shall forward
the full report to the individual or his or her guardian, the area agency
executive director, and the program involved, if any. Section requires
follow up when a complaint report is finalized and contains
recommendations for resolution that require the AA, program, or bureau
action. Such action shall be taken within 20 business days of the date of the
final report, unless a shorter timeline is specified. The AA or program shall
send written documentation of such actions to the complaint investigator and
bureau upon completion. The bureau shall follow up as needed to ensure
implementation of the actions. The rule allows an AA to conduct its own
investigation but only after the complaint report by OCLS is final.

202.09 Complaint Investigator Training and Data collection is
comprehensive. OCLS has-developed a process for informal as well as formal
reviews of complaints that creates a more efficient and responsive process.

BDS has the authority to make program and systemic recommendations as a
result of its investigations of complaints, unlike APS. This allows for a
broader review and potential systemic correction for allegations of incidents
that may have a root cause that is in addition to the abusive or neglectful
actions of an individual perpetrator. However BDS only accepts complaints
that involve persons applying for, eligible for, or receiving services from area
agencies or developmental services or acquired brain disorder programs
funded through the bureau of developmental services.

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Findings: New Hampshire has established processes to assure the reporting,
investigation, and follow up of allegations of abuse, neglect, exploitation and
other areas of complaints. The involved entities work together to share
information and findings and relevant information is shared with the Area
Agencies to assure follow up by providers. The coordination and sharing of
information is positive. However, there appears to be some duplication of
effort. The rules make both APS and OCLS responsible to investigate abuse,
neglect and exploitation without any clear distinction. When I met with OCLS,
APS and HFLU staff they told me that OCLS and APS often undertake an
investigation together and are sometimes joined by a licensing inspector.
There are limited staff resources in Licensing and OCLS. It is not an efficient
use of resources.

The fact that there are three entities (and probably a fourth with the
Department of Education needing to investigate abuse and neglect allegations
within the school program) presents concerns for Lakeview and the quality
oversight system. Lakeview has varied reporting and follow up requirements
that are exacerbated by reporting requirements of other states.

Lakeview also only has to follow up on the systemic issues that cause or
contribute to abuse and neglect for its New Hampshire residents. New
Hampshire has no comprehensive picture of the systemic issues that are
present at Lakeview or other facilities in the state that may serve out of state
residents because the BDS OCLS does not assume responsibility for the
complaints of issues involving these individuals. I recommend that the rules
that prohibit OCLS from reviewing all complaints and providing feedback to
Lakeview and similar facilities be revised so that all complaints are known to
DHHS. If New Hampshire decides to become responsible to investigate all
complaints and determine the systemic causes of allegations involving
residents of Lakeview from other states, BDS will need additional staff
resources to investigate and assure follow up or individuals from other
states. The Area Agencies are only responsible to assure follow up for
individuals who they fund.

The responsibility of the AAs to ensure follow up by providers in response to
complaint findings is clear. However, each AA has no more than three
individuals at Lakeview and some AAs have only One individual. The systemic
findings are shared with AAs individually. No one is responsible to review all

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of the New Hampshire complaints for the facility and determine what
patterns of concern are evident.

I requested a summary of all complaints and allegations of abuse and neglect
that involved residents of Lakeview since 2011. I was finally provided the
summary on March 25th. There were 241 reports from 2011 through 2/9/15.
Thirty- four of the allegations were founded and twenty- five remained
opened. This is a substantiation rate of 16% of the completed investigations.
This is approximately half of the national trend of 30-35% of allegations
being substantiated. I believe that APS inability to substantiate an allegation
without an identified perpetrator contributes to this low rate.

One example of this systemic weakness is portrayed in an investigation of an
individual being bitten by another individual. There was no perpetrator
identified, the individual was on 15-minute checks and had received medical
attention and was healing. There did not seem to be a review of the other
resident?s level of supervision or whether either?s supervision was
appropriate. In another case an individual went without glasses for four
months. APS could not specify if the nurse or the case manager was
responsible so did not have an individual perpetrator. It also noted the staff
were no longer at LNC. Individuals were harmed in both situations that may
have resulted from systemic weaknesses at Lakeview. It is a failure of 
oversight system that this cannot be identified and therefore goes
unaddressed by the provider.

There are other examples of what appears to be a lack of thoroughness in the
investigations, although I have not reviewed the entire investigations only
the brief summaries shared with me. An incident was reported on 10/ 18/ 14
that involved two residents being found alone in one of the bedrooms. It was
unfounded because individuals were on 15- minute checks and these were
being performed. The investigation did not address that a minor was able to
be in the bedroom of a person of majority. The investigation did not appear to
suggest any future protections be put in place or training for staff.

Twenty-five of the investigations are still opened. The majority is from
October 2014. The expectation is that OCLS will complete investigations
within fifteen days. The fact that this many are opened may indicate that
OCLS is not sufficiently resourced to meet the requirements of the agency?s
rules in this area.

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Recommendations: New Hampshire needs to address two critical
weaknesses in its rules or the interpretation of these rules. First, APS needs
to expand its investigatory role to be able to identify abuse and neglect that is
attributable to organizational failure to protect individuals and not be limited
to substantiating allegations only when there is an identified perpetrator. If
this is not possible all allegations without an identified perpetrator or that
may have programmatic or systemic cause should be referred to OCLS that
has the authority to make systemic findings.

Secondly the responsibility of OCLS needs to be expanded to include a review
of complaints of all residents of Lakeview regardless of their state of origin,
unless responsibilities are broadened as I have suggested. The residents
and families need to be assured that the state is monitoring and overseeing
the safety and care for all individuals who reside at Lakeview; that it is aware
of any and all systemic and organizational weaknesses that contribute to
abuse, neglect, exploitation and poor care; and that it requires Lakeview to
implement corrective action. OCLS in coordination with HFLU
should have the responsibility to review the findings and trends of all
investigations and complaint reviews (including those performed by DCYF,
DOE and other states? protective service agencies) to provide feedback to the
administration of DHHS regarding the overall quality of care and to
determine the facility?s licensing status if Lakeview remains open. DCYF or
another entity needs to investigate allegations of neglect of children by staff.

DHHS needs to complete a staffing analysis of OCLS and APS to determine if
there is sufficient staffing to carry out their responsibilities. It should also
more clearly delineate the roles of the two units in completing investigations
and complaint reviews to use staff efficiently and to ensure the efforts of the
two units are well coordinated. I saw efforts to begin to address this need for
coordination when I met with DHHS staff.

Section V. The Role of the Area Agencies
Area Agencies have the overall responsibility to ensure the delivery of
services for individuals with developmental disabilities within their region

and to assure the quality of the service providers. They fulfill the service
coordination responsibility for these individuals and are charged to develop

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the capacity needed by their citizens. Their responsibilities are defined in
their contract with DHHS and in rule.

301 defines the rights of persons receiving developmental services or
acquired brain disorder services in the community. The purpose of these
rules is to define the rights of applicants for service or persons who have
been found eligible for services under RSA 171-A: 6 and who are being served
in the community or in a state?operated designated receiving facility.
Individuals have additional rights under RSA 151:21, patients? bill of rights
for residents of health care facilities.

This rule is comprehensive and clear. 310.06 (3) asserts the right to
receive services in such a manner as to promote the individual?s full
participation in his or her community and (15) the right to have
individuals of one?s choosing at the service-planning meeting. 310.09
(1-3) assures the right to safe and sanitary and humane living conditions,
to freely and privately communicate with others and the right to privacy.

503, Eligibility and the Process of Providing Services establish
standards and procedures for the determination of eligibility, the
development of service agreements, and the provision and monitoring of
services which maximize the ability and decision making authority of persons
with developmental disabilities and which promote the individual?s personal
development, independence and quality of life in a manner that is determined
by the individual.

The requirements of 503.08 and seem very pertinent to
setting different expectations for the quality of care at Lakeview.
All services shall be designed to:
1. Promote the individual?s personal development and quality of life
in a manner that is determined by the individual;
2. Meet the individual's needs in personal care, employment, adult
education and leisure activities
3. Promote the individual?s health and safety
4. Protect the individual?s right to freedom from abuse, neglect and
exploitation;
5. Increase the individual?s participation in a variety of integrated
activities and settings;

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6. Provide opportunities for the individual to exercise personal
choice, independence and autonomy within the bounds of
reasonable risk;

7. Enhance the individual?s ability to perform personally meaningful
or functional activities;

8. Assist the individual to acquire and maintain life skills, such as,
managing a personal budget, participating in meal preparation. Or
traveling safely in the community; and

9. Be prOvided in such a way that the individual is seen as a valued,
contributing member of his or her community.

The environment or setting in which an individual receives services
shall promote that individual?s freedom of movement, ability to make
informed decisions, self-determination, and participation on the
community.

I cite these rules because they are an expression of New Hampshire?s
expectations for service delivery. These expectations should more
clearly drive the planning and service delivery for the individuals placed
at Lakeview by the Area Agencies and be re?ected in the Individual
Service Plans.

Service Coordination is an integral part of coordinating ad assuring
quality services. 503.09 specifies the responsibilities of Service
Coordination
The Service coordinator shall be a person chosen or approved by
the individual or guardian and approved by the area agency,
provided that the area agency shall retain the ultimate
reSponsibility for service coordination.

The Service Coordinator is expected to act as an advocate for the
individual, coordinate the service planning process, ensure continuity
and quality of services, indicate actions to be taken when goals are not
being addressed, and convene service planning meetings at least
annuaHy.

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Service Planning expectations are outlined in 503.10. They
require that the individual or guardian may determine the following
elements of the service planning process:

1) The number and length of meetings;

2) The location, date and time of meetings;

3) The meeting participants; and

4) Topics to be discussed

Delineates the review of service agreements by the area agency with
the individual or guardian at least once during first 6 months and that
annual review is required.

Delineates that the service coordinator is responsible for monitoring
services identified in the service agreement and for assessing individual,
guardian and family satisfaction at least annually for basic service
agreements and quarterly for expanded service agreements.

The service coordination responsibility for the Area Agency is clearly to
drive the system for the benefit of the individual and family. In essence,
they are the frontline of the Area Agency to assure well coordinated
planning and services for indiViduals. It does not appear that all of these
responsibilities are being carried out consistently for individuals who
reside at Lakeview. Families report that planning meetings are totally
dictated by Lakeview and they have little control over the scheduling of
the meetings or the agenda. Families do not report that their perception
of service delivery or their satisfaction is always being asked by Service
Coordinators.

Part 506 outlines the staff qualifications and staff development
requirements for developmental service agencies. The purpose for these
rules is to outline the minimum qualifications of provider agency staff,
and the training requirements for such staff. These are weak with little
specificity in the areas of medication certification, safety, habilitation,
nursing, restraint training, abuse and neglect, person-centered service
delivery. There does not appear to be a qualification process for
providers other than to meet basic licensing standards.

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Part 505 Establishment and Operation of Area Agencies defines
the procedures and criteria for the establishment, designation, and re-
designation of area agencies, and to define their role and
responsibilities. The primary responsibility of the area agency shall be
to plan, establish and maintain a comprehensive service delivery system
for individuals who are residing in the area. The area agency shall plan
and provide these services according to rules promulgated by the
commissioner.

Re-designation states the broad functions of an Area
Agency including three responsibilities that are pertinent to Lakeview.
These are the responsibilities in to:

1) Demonstrates through multiple means, its commitment to
individual rights, health promotion and safety; (2)

2) Provides individuals and families with information and supports
to design and direct their services in accordance with their
needs and preferences and capacities and to decide who will
provide them; 

3) Continually asses and improves the quality of its services, and
ensures that the recipients of services are satisfied with the
services they receive; (5)

517 addresses Medicaid ?Covered Home and Community ?Based
Care Services for Persons with Developmental Disabilities and Acquired
Brain Injuries. The purpose of these rules is to define the requirements
and procedures for Medicaid-covered home and community-based care
waiver services for persons with developmental disabilities and
acquired brain disorders where such services are provided pursuant to
503, 507, 513, 518,521, 522, 525 and 10. A pertinent section to
this review is in 517.04 Provider Participation:

A residence funded under the home and community-based care waiver
that provides services to persons with acquired brain disorders and is
licensed as a supported residential care facility or a residential
treatment and rehabilitation facility under RSA 151:2, shall not be

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required to be certified as a community residence pursuant to 
1001. (Italics mine). This means that Lakeview is not being held to the
same requirements as all other waiver providers that appear to be more
extensive than the licensing requirements of a RTRF.

Area agencies are enrolled with the NH Medicaid program as providers
in order to receive reimbursement for the provision of services under
the home and community based waiver. Then when the services are to
be provided by a subcontractor the area agency establishes a contract
with the subcontractor specifying the roles of the area agency and
subcontracting agency in the service planning, provision and oversight.
New Hampshire recently underwent a quality review by CMS for the
HCBS program. Richard Greal, Associate Regional Administrator, CMS
wrote to Commissioner Toumpas on March 15, 2015 stating that New
Hampshire?s ?quality assurance and improvement processes and
procedures are implemented and in place for the HCBS waiver.? New
Hampshire uses HCBS waiver funding to pay for the individuals who
receive services from Lakeview but exempt from the normal
waiver qualification and oversight process.

I had two opportunities to interview administrators from the Area
Agencies and on one occasion from the Community Support Network,
Inc. (CSNI), the group that represents all ten of the Area Agencies and
coordinates some of their joint efforts. As has been noted in the
Lakeview report and earlier in this report, the Area Agencies began
having systemic concerns about Lakeview in 2013 and began meeting
with Lakeview administrators in late 2013 early 2014. The Area
Agencies report that they did not start to regularly make referrals to
Lakeview until 2010/2011. At that time they found an increase in
individuals with complex developmental and needs
who exhibited aggressive and violent behaviors. They were not finding
providers with the capacity to serve this population.

Area Agency Service Coordinators completed a client survey for
individuals who were served at LNC. The result of the survey
highlighted concerns with incident reporting, communication among
Lakeview employees, communication with the Area Agencies, an
inability to meet deadlines, complaint reporting and follow up of

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corrective action. The CSNI Quality Improvement Committee noted
concerns with staff retention and a growing reliance on police
intervention as a result of Lakeview?s no restraint policy.

The Area Agencies held two meetings with the administration of
Lakeview and submitted expectation for improvement to Lakeview on
2/3/14. The Q1 Committee then initiated QI reviews at
Lakeview and held quarterly meetings with the administration to
review concerns. Regular onsite reviews were initiated in the spring
and became daily in October 2014. These review efforts continue. The
QI Committee of CSNI recently issued a letter to Lakeview (3/15) that
expressed their concerns that Lakeview was regressing in its ability to
meet the expectations outlined by the AAs in their letter of 2 14.

CSNI and the Area Agencies are also working with BDS to develop long-
range community solutions and increase community provider capacity
to address the needs of individuals who reside at Lakeview or
individuals with similar needs that may be referred in the future. The
AAs are working with START to develop transition plans for current NH
citizens who are residents of Lakeview. At least four individuals have
left Lakeview from NH. One individual was placed at FINR and the other
three were able to transition to the community. The individual was
placed at FINR through a private insurance company that is funding this
man?s placement. 

Findings: I think the actions the Are Agencies are taking to monitor the
services at Lakeview are reasonable and meet the responsibilities they
have for assuring quality services for individuals in their areas. In
addition to the overall monitoring that has taken place for almost a year,
they regularly review the findings of APS and OCLS and require follow
up by Lakeview. They also review any use of restraints and the PRN use
of medications. I recommend that all planned use of
medication at Lakeview undergo both a peer review and a
human rights review.

The monitoring and oversight has been made a priority by the Area
Agencies over the past year and significant resources have been devoted
to the effort. However, there is no indication of an expectation that
action will be taken against Lakeview if significant improvement is not

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made. There is also no performance standards set for Lakeview to meet
in each area of deficiency. The Area Agencies and the state need to
determine for how long they will allow inadequate care of their citizens
to go on without measurable improvement. A decision to revoke a
license and stop funding a provider is always a difficult one and must be
based on criteria, factual data and evaluation. It is more difficult for New
Hampshire to make an objective decision about Lakeview?s future while
it does not have sufficient community resources to fully respond to the
needs of Lakeview?s current residents.

I am concerned that no entity has a contract with Lakeview. Lakeview is
licensed by DHHS and each Area Agency funds and approves services
for individuals through individual service authorizations. These
authorizations specify the expectations for the services the individual
will receive. However there is no contract that sets requirements for
Lakeview as a service provider in terms of its policies, procedures,
administrative practices, staff training and selection, clinical and health
support services, quality assurance, etc. The Area Agency Directors
indicate they have contracts with the other sub-contractors (providers)
that operate Within their jurisdiction. A contract is the normal
mechanism to set program and administrative expectations that are
above the basic requirements of licensing. The fact that there is no
contract also means that there is no requirement for Lakeview to submit
cost reports or certified audits. To my knowledge no entity in New
Hampshire reviews or is knowledgeable of Lakeview?s costs or budget.

It is difficult for any one Area Agency to focus significant attention on
Lakeview. Each AA serves hundreds of individuals and contracts with
numerous providers. No one AA appears to have more than three
individuals at Lakeview. It is to the Area Agencies credit that they have
used CSNI to coordinate their efforts to monitor and oversee services
for Lakeview residents. CSNI sponsors a QI Committee giving all of the
AAs a chance to share their findings.

It is troubling that the expectations set out in the rules of Section 505
are not made applicable to individuals at Lakeview. Lakeview serves
over 60 individuals is an isolated setting that by its nature cannot meet
all of the expectations for community inclusion and individualization.
However, the Area Agencies should expect a program to provide

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individuals with the ability to determine their services, involve their
families in a meaningful way, meet their needs for employment and
leisure, and engage in meaningful activities and acquire skills.
Individuals and their families should have a much more significant role
in the service planning process than they are afforded by Lakeview or
the Area Agency Service Coordinators.

Recommendations: If Lakeview remains licensed by DHHS and
utilized by New Hampshire residents it should have a contractual
relationship with the state just as other providers of services to
individuals with developmental disabilities have. Options to accomplish
this would be to identify a lead AA or establish a contract with CSNI as
the administrator for the Area Agencies.

Service coordination is at the heart of an effective service delivery
system. Families who were interviewed report uneven responsiveness
from their AA Service Coordinators. It may be difficult to achieve this
consistency across ten AAs on a continual basis when each has service
coordination responsibility for only one to three individuals. Families
need this support and may rely on it more strongly when their children
are placed far from home and the goal is to plan their transition back to
the community. Area Agencies might be able to improve service
coordination if they agreed to share one service coordinator who was
assigned to support all of the NH Lakeview residents. This staff can
become more of an expert on the services at Lakeview, the staff who
provide them and note trends in service delivery and program planning.

VI. Summary

There are elements of New Hampshire?s oversight and monitoring that
are very workable and other areas that need significant re-structuring
to meet the state?s obligation to its citizens and those from other state?s
placed within its borders to be free from harm, safe and provided
quality supports and services to experience a meaningful life within its
communities.

New Hampshire appears to have a provider certification process for its
HCBS waiver providers but does not have a similar process for an entity

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wanting to operate as a RTRF. I recommend that New Hampshire
determine if its existing provider qualification process is sufficient to
ensure providers wanting to operate in the state can demonstrate the
capabilities New Hampshire expects of its providers. The certification
process should be an extensive review of a new provider and require
documentation of policies and procedures, evidence of fiscal integrity,
staff hiring and training requirements, protection of individual?s rights
including their finances, and administrative oversight and supervision.
Providers should demonstrate an understanding of habilitative
programming and person-centered planning. They should be required
to submit relevant documentation and demonstrate basic proficiency in
all areas before they are certified to become a provider in New
Hampshire.

Throughout the report I have made recommendations for
improvements in the rules; licensing process; abuse, neglect and
exploitation investigatory process; the complaint process; and the
provider oversight process.

New Hampshire has a structural problem in that these functions are not
well integrated to insure similar expectations for the review of abuse,
neglect and unusual incidents regardless of age or state resident status,
and for the overall review and monitoring of the quality of services of
providers such as Lakeview. New Hampshire needs to better align the
responsibilities of the and DCYF to investigate in
these areas. It needs to strengthen its rules for and develop
quality service expectations in addition to the basic licensing
requirements. It needs to assure its quality monitoring system protects
all residents of facilities it licenses or certifies including individuals who
are placed from other states.

New Hampshire needs an integrated service review process that is
triggered by a program?s inability to meet the standards over a set
period of time and to consistently maintain its adherence to these
standards. An effort needs to be made to regularly bring together the
results of reviews by investigators, surveyors, Area Agency service
coordinators and program quality review staff to review data in an
integrated and coordinated manner. Such a review may be best
described as a Program Integrity Review. It would consider incident

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data, investigation data, progress toward meeting program measures,
consumer and family satisfaction, use of restrictive programming,
staffing and staff training and fiscal data. It would bring together experts
in each of these areas to review the data and determine if the provider is
meeting expectations, making progress or in need of corrective action.
Such an effort can only be useful to consumers, families and funders if
performance measures and criteria for changes to the provider?s status
when warranted are established by the State. A Program Integrity
Review might lead to corrective action requirements, technical
assistance, enhanced program monitoring, provisional licensure or
certification, or revocation. It can provide the state with a coordinated
quality assurance mechanism to support effective decision making
about provider ability and capacity to provide quality services, safe
environments and settings that keep individuals free from harm.

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