A lack of state oversight and rigorous licensing procedures allowed neglect and abuse to persist for years at a New Hampshire facility for people with brain injuries, according to an independent investigation requested by Gov. Maggie Hassan.
Separately, New Hampshire's education commissioner is shutting down Lakeview NeuroRehabilitation Center's special education program and ordering any school districts that send children to Lakeview to find new arrangements for those students within 60 days.
The investigation, released Monday, examines the state Department of Health and Human Services' oversight of Lakeview, in Effingham. The Disability Rights Center filed complaints against Lakeview last year that detailed reports of abuse and neglect that included residents being left unattended or hurting staff and each other, prompting a state investigation that found extensive staffing and training deficiencies.
Monday's report, prepared by Kathryn du Pree, president of Crosswinds Consulting, focused specifically on the state's oversight and licensing of the facility. It found the department failed to file and keep adequate records of site visits or keep a coordinated list of complaints that could have revealed widespread issues. There also is no state procedure in place to respond to complaints involving out-of-state residents who comprise most of the roughly 60 people at Lakeview.
"We have a responsibility to ensure that we are doing everything possible to protect the health and safety of our most vulnerable citizens," Hassan said in a statement. "These reports make clear that we can and must do better."
A series of state reviews of Lakeview never highlighted many of the chronic problems outlined in complaints by the Disability Rights Center and other groups, the report found.
"If they had been noted, Lakeview could have either 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," the report says.
Lakeview did not respond to a request for comment on the report's finding, but Executive Director Patricia Reed said she plans to appeal the decision to end the special education program.
The report outlines a number of recommendations that Hassan is ordering the Department of Health and Human Services to implement, including restructuring the licensing unit, improving coordination between the health department and outside agencies that provide services for residents and maintaining a freeze in admissions. It also was critical of Hassan for not providing enough funding for inspectors in her budget.
Karen Rosenberg, senior staff attorney at the Disability Rights Center, was pleased by the order to shut down Lakeview's special education program and remove the students within 60 days. The report, she said, raises the question of whether the center should be allowed "to operate a day longer."
"It's raised some very serious concerns about whether Lakeview even has the capacity to offer the kinds of programs it holds itself out as being able to provide," she said.
Health and Human Services Commissioner Nick Toumpas said the report shows the state must take a "critical look" at the existing regulatory structure and make changes to ensure patient safety.