‘Virginia M. Bary, Ph. Paul K. Leather Sopmisitare erator Deputy Cammisna ef Eaton Tal soonsiae eee Seot STATE OF NEW HAMPSHIRE DEPARTMENT OF EDUCATION 01 Pleasant Stroot Concord, NH 0301 PAK 603-271-1983 Ccizens Services Line 1-800-399-0000 March 11, 2015 Tina Trude!, Chief Operating Officer Lakeview Neurorehabilitation Center 244 Highwatch Road Effingham, NH 03882 Re: Evidence submitted for the Special Monitoring (RSA 186-C: §) Findings of Noncompliance Dear Dr. Trudel: The New Hampshire Department of Education (NHDOE) Bureau of Special Education (ureau)has conducted a subsequent unannounced on-site visit on February 26, 2015. Thisis the third on-site vis for Lakeview School. Previous visits were made on October 10, 2014 and October 29, 2014, Lakeview School was notified of these two visits the aftemoon prior. The intent of February 26, 2015 on-site was to observe evidence of correct implementation of the New Hampshire Rules for the Education of Children with Disabilities, Amended May 15, 2014 (NH Rules) as well as to review the elementary high school curriculum. in addition to the on-site visits, the NHDOE also offered weekly teleconferences with the staff at Lakeview School from December 10, 2014 to January 28, 2015 to provide Lakeview School the opportunity for technical assistance. The NHDOE informed Lakeview School of the areas of noncompliance in letters dated November 12, 2014, January 7, 2015, and January 26, 2015. In each of these letters the area of noncompliance was identified and corrective actions were provided along with specific timelines for the submission of ‘evidence of correct implementation of the NH Rules. The NHDOE used various methods and fools to determine appropriate implementation of the NH Rules such as three on-site visits, classroom observations, staff interviews, and evidence provided by Lakeview School. The Lakeview School has shown throughout the last several months a consistent pattem in the severity, length, and repetitive nature of the findings of noncompliance. Based on evidence submitted December 16, 2014 the NHDOE identified nine additional findings of noncompliance related to Policies and Procedures. On December 19, 2014, December 22, 2014, December 29, 2014, and January 26, 2015 the NHDOE found evidence of additional areas of noncompliance as well as on the most recent visit, February 26, 2015, where the NHDOE determined sixteen adcitional areas and/or incidences of continued findings of noncompliance. Three findings have been resolved. All other findings of noncompliance remain, Based on the lack of correction of noncompliance Lakeview School continues to be on provisional approval. This means Lakeview School shall not accept any additional students, either students with disabilities from New Hampshire or any other state until the NHDOE removes the provisional approval. Below is an outline of all areas of noncompliance that have been identified. D Access: Relay NH 744‘Tina Trude, Chief Operating Officer Lakeview Neurorehabiltation Center March 11, 2015 Page 208 32 ‘Additional Findings of Noncompliance Identified on February 26, 2015 Cerlification and Licensure Program, Ed 1114.05(j) All administrative, instructional, and related service staff shall hold appropriate certification or licensure for the position in which they function as required by the state of New Hampshire, and other licensing entities. The determination of credentials required shall be made by the department. Ed 1114.10{q) All administrative, instructional, and related service statt shall hold approoriate certification for the position in which they function as required by the State of New Hampshire or other licensing entity evidence of such qualification shall be on record with the program. Lakeview Schoo! has a staff listed on the January 21, 2015 personnel roster as a Teacher Assistant, who by self-report is currently functioning as a teacher. This individual holds no current teacher certification. ‘Action Required: Lakeview School must remove this individual from the role of teacher. Lakeview ‘School must provide the NHDOE with the name and current credentials of the teacher who will be replacing this individual. Evidence of Correction of Noncompliance Due: | Evidence Received: March 26, 2015 Not yet received. Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of ‘the noncompliance. This area continues to be a finding of noncompliance. * Required action: Lakeview School must remove this Individual from the role of teacher. Lakeview Schoo! must provide the NHDOE with the name and current credentials of the teacher who will be replacing this individual. ° nce rs ing the Feb 2015 on-site visit ‘= The monitoring team interviewed a staff member who was instructing students in English/Language Arts. In reviewing the January 21, 2015 personnel roster, Lakeview School identified her as a Teacher Assistant. However, upon further investigation, it was discovered that she had an expired teaching certificate. The individual reported to the monitoring team that she had been acting as a substitute teacher for the last several months. Though the staff member indicated that she has a Statement of Eligibility for Special Education, the NHDOE Bureau of Credentialing has no record of her being employed by Lakeview School. Program Requirements: Requirement for Employment Ed 503.02 Exceptions. Notwithstanding the requirements of Ed 503.01, a schoo! district may employ: (a) Anon-credentialed substitute teacher who may teach up to 20 consecutive days during the school year in the same position without holding an endorsed credential from the bureau. The Lakeview School staff member noted in the above finding reported being paid as a substitute teacher for the last several months. This individual holds no current teacher certification. ‘Action Required: Lakeview School must remove this individual from the role of teacher. Lakeview School must provide the NHDOE with the name and current credentials of the teacher who will be replacing this individual. Evidence of Correction of Noncompliance Due: | Evidence Received: March 26, 2015 Not yet received. Review Status: | As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance.‘Tina Trudel, Chief Operating Officer Lakeviow Neurorohabiltation Certor March 11, 2015 Page 3 of 32 © Required action: Lakeview Schoo! must remove this individual from the role of teacher. Lakeview Schoo! must provide the NHDOE with the name and current credentials of the teacher ‘who will be replacing this individual. © Evidence reviewed during the February 26,2015 onsite vs The monitoring team interviewed a staff member who was instructing students in English/Language Arts. In reviewing the January 21, 2015 personnel roster, Lakeview School identified her as a Teacher Assistant. However, upon further investigation, it was discovered that she had a teaching certificate that expired in 2005. The individual reported to the monitoring team that she had been acting as a substitute teacher for the last several months. Though the staff member indicated that she has c Statement of Eligiblty for Special Education, the NHDOE Bureau of Credentialing has no record of her being employed by Lakeview School. Program Requirements: Certification and licensure Ed 1114.05() All administrative, instructional, and related service staff shall hold appropriate Certification or censure for the position in which they function as required by the state of New Hampshire, and other licensing enfities. The determination of credentials required shall be made by the department. Ed 1114.10{a) All administrative, instructional, and related service staff shall hold appropriate Certification for the position in which they function as required by the State of New Hampshire or other licensing entity evidence of such quaiification shall be on record with the program. Lakeview School has a staff member with an assignment of Special Education Teacher. The staff member has beginning educator cerfification though does not have a special education ‘endorsement. She does not have endorsements in the content areas she is teaching (social studies ‘and math), and there is no social studies consultant hited by Lakeview School. Though the staff member indicated that she is working under the Alt. 4 Certification for Special Education, the NHDOE Bureau of Credentialing has no record of the staff member being employed by Lakeview School. ‘Action Required: Lakeview School must either show evidence that this individual has an Alt 4 or remove this individual from the role of teacher. If removed, Lakeview School must provide the NHDOE with the name and current credentials of the teacher who will be replacing this individual. Evidence of Correction of Noncompliance Due: _| Evidence Received: March 26, 2015. Not yet received. Review Status: ‘As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. * Required action: Lakeview Schoo! must elther show evidence that this individual has an Alt 4 or remove this Individual from the role of teacher. If removed, Lakeview School must provide the NHDOE with the name and current credentials of the teacher who will be replacing this individual. © Evidence reviewed during the February 26, 2015 on-site visit; = The monitoring team was informed that there was a new hire in the High School Program. Although this individual has a teaching credential, the individual does not have endorsements in special education or in the high school content areas she is teaching. This individual does have a statement of eligibility but based on the fimelines for submitting an individual professional development pian, the Director of Education could not tell the monitoring team the date she was hired therefore the monitoring team could not determine whether she has an ‘appropriate certification or license. Although Lakeview School has hired her in the role of teacher the NHDOE Bureau of Credentialing has no record of her being employed by Lakeview School to follow-through with an Alt, 4 Certification.‘Tina Trudel, Chief Operating Officer Lakeview Neurorehabillaon Center March 11, 2015 Page 4 of 32 Cerlification and Licensure. Program Ed 1114.05() All administrative, instructional, and related service staff shall hold appropriate Cerfification or licensure for the position in which they function as required by the state of New Hampshire, and other licensing entities. The determination of credentials required shall be made by the deparlment. Ed 1114.10(a) All administrative, instructional, and related service staff shall hold appropriate Certification for the position in which they function as required by the State of New Hampshire or other licensing entity evidence of such qualification shall be on record with the program. Lakeview School currently has an art class that is on the High School program's schedule but there an art teacher does not appear on the January 21, 2015 personnel roster. Noris there a consultant on the January 21, 2015 personnel roster who is endorsed in 0200 Art Education. ‘Action Required: Lakeview School must have either a cerfified Art teacher to instruct the Art class or provide a signed contract for an individual cerfified in Art who will provide consultative services and evidence that the consultant is meeting with teachers who are teaching that subject area from September 1, 2014 to the present. Evidence of Correction of Noncompliance Due: | Evidence Received: ‘March 26, 2015 Not yet received. Review Status: | As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. «Required action: Lakeview School must have either a cerfified Art teacher to instruct the Art class or provide a signed contract for an individual certified in Art who will provide consultative services and evidence that the consultant is meeting with teachers who are teaching that subject area from September 1, 2014 to the present. © Evide 1d during the 15 on-si ‘= Lakeview School provided a High School Schedule for 2014-2015 with a section for Art and a first name of a staff member that does not appear on the January 21, 2015 personnel roster as either professional staff or consultant. Art classes ‘appear on Mondays on the schedule provided by the Director of Education. ‘Ceriification and Licensure: Program Ed 1114.05() Al administrative, instructional, and related service staff shall hold appropriate certification or licensure for the position in which they function as required by the state of New Hampshire, and other licensing entities. The determination of credentials required shall be made by the department, Ed 1114,10(a) All administrative, instructional, and related service staff shall hold appropriate certification for the position in which they function as required by the State of New Hampshire or ‘other licensing entity evidence of such quaification shall be on record with the program. Lakeview School has not nofified the NHDOE Bureau of Credentialing of a staff member who moved from the Lakeview Schools approved special education programs into a different program where ‘their new position is teacher. ‘Action Required: Lakeview School must provide evidence that the Bureau of Credentialing was informed that this individual is no longer employed at Lakeview School and Lakeview is no longer supporting his Alt 4. Evidence of Correction of Noncompliance Due: | Evidence Received: March 26, 2015 Not yet received. Review Status: | As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance.‘Tina Taudel, Chief Operating Officer Lakeview Neurorenabitation Centor March 11, 2015 Page 5 of 32 + Required action: Lakeview School must provide evidence that the Bureau of Credentialing was Informed that this individual is no longer employed at Lakeview School and Lakeview is no longer supporting his Alt 4 © Evidence reviewed during the February 26, 2015 on-site vist; * Lakeview Schoo! noted that the teacher was not on the personnel roster. The Director of Education said that the teacher was now the "Director of the Young Adult Program." When asked when he left the school, the Director of Education reported that he had been “out for a ile while.” When asked if Lakeview ‘School notified the NHDOE that he was no longer employed as a teacher on an ‘Alt. 4 cerlification program, the Director of Education reported that she sent an ‘email to Lisa Landenberger at NHDOE Bureau of Credentialing. The Director of Education was not able to produce the emai, but did state that the staff member was no longer employed at the Lakeview School and that he had been approved under an Ait. 4 certification program. The monitoring team explained that the Alt. 4 program involves the school and the administrator making a commitment to the State and that the Alt. 4 had been approved under the Director of Education's signature. The monitoring team then again ‘asked directly if the Director of Education had notified the NHDOE that this ‘employee was no longer employed at Lakeview School, and the Director of Education replied "No." Program Requirements: Cerfification and Licensure Ed 1114.05() All administrative, instructional, and related service staff shall hold appropriate certification or censure for the position in which they function as required by the state of New Hampshire, and other licensing entities. The determination of credentials required shall be made by the department. Ed 1114.10(a) All administrative, instructional, and related service staff shall hold appropriate certification for the position in which they function as required by the State of New Hampshire or other licensing entity evidence of such qualification shall be on record with the program. Lakeview School's personnel roster includes a list of ten consultants. Lakeview School provided their consultant log, which verified that the schoo! has contracts with four consultants. Of those four Consultants, two have consulted with the staff at Lakeview School. Per Bureau of Special Education FY'10 Memo #18, “There may be circumstances when private special education schools hire or contract with consultants. Individuals who act in the role of consultants must be certified in the area in which they are consulting." ‘Action Required: Lakeview School must provide a signed contract for certified individuals in areas that the teaching staff do not hold current certifications and evidence that the consultant is meeting with teachers who are teaching that subject area from September 1, 2014 to the present. Evidence of Correction of Noncompliance Due: _| Evidence Received: March 26, 2015 Not yet received. Review Status: ‘As of March 11, 2015, Lakeview Schoo! has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. + Required action: Lakeview School must provide a signed contract for certified individuals in areas that the teaching statt do not hold current certifications and evidence that the consultant Is meeting with teachers who are teaching that subject area from September 1, 2014 to the present. ° Evi reviewed during the February 26, 2015 on-site visi = The Director of Education provided a binder of their consultants and evidence cof consultation. Lakeview School provided a list of ten content areas and names but of those ten Lakeview Schoo! only had signed contracts for five of the consultants and of those, one is not signed by Lakeview School. Of those‘Tina Trudel, Chief Operating Officer Lakeview Neurorenabitation Center March 11,2015, Page 6 of 32 five, only three had documentation confirming any consulting services to Lakeview School. One had one meeting documented in January 2015 with principal and teachers though there was no evidence of a contract in the binder. The second had two sessions, one in October 2014 and one in December 2013 and evidence of a meeting with a staff in December 2014. The third had sessions with the Director of Education January 2015. = Lakeview School notes one teaching staff on the personnel roster: PE Teacher: and two contracted consultants with documentation of meetings with staff: Mathematics (5-8) and English (5-12). For the Elementary Program, there is no qualified staff: reading specialist brary media specialist, art or music, guidance Counselor, information and communication technology, mathematics, and elementary (K-6 or K-8). At the High School Program, there is no qualified staff: library medial specialist, art or music, guidance counselor, information and communication technology, mathematics, science, social studies, ELA, family & Consumer science, technology education, business, and world languages. Responsibilities of Private Providers of Special Education or Other Non-LEA Programs in the Implementation of IEPs. Ed 1114,06(f) Daily lesson plans shall be clear, concise, and refiective of the IEP goals for each child. They shall reflect any staff input and related reports and evaluations provided by the agencies responsible for the student's education and welfare. Lakeview School was not able fo provide lesson plans for all the High School, Day program and Elementary, Day program classrooms. ‘Action Required: Lakeview School must show evidence of daily lesson plans from September 1, 2014 for all classes taught. Evidence of Correction of Noncompliance Due: _| Evidence Recelved: March 26, 2015, Not yet received. Review Status: | As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘+ Required action: Lakeview School must show evidence of daily lesson plans from the beginning of this school year for all classes taught. ° Evi is ying the February 26, 20) ite vist: * Staff reported not keeping daily lesson plans. When the monitoring team asked the Director of Education how they check lesson plans she stated that she does walk-throughs, supervision in classes, trainings and the provision of time to support teachers for lesson planning. They reported that teachers are supposed to use "On Course,” an online lesson planning program, and commented that they should be doing them but that they are probably not using the program as consistently as they should.‘Tina Trudel, Chet Operating Officar Lakeview Nourorehabiltation Conter March 11, 2018 Page 7 of 32 ‘Responsibilities of Private Providers of Special Education or Other Non-LEA Programs in the: Implementation of IEPs Ed 1114.06 {9} Each private provider of special education or other non-LEA program shall maintain progress information for each child with a disability on an ongoing basis in accordance with 34 CFR 300.600} (1) (h) A mic-year review and annual evaluation of each child's progress relative to the written IEP shall be conducted by the sending LEA and the private provider of special education or other non-LEA program. {) If private provider of special education or other nor-LEA program determines that any ct @ disabilty placed at the facility or program is not making progress toward meeting his or her IEP goals at the rate anticipated, the facilfy or program shall immediately contact the LEA for the Purpose of reviewing the IEP and considering modifications. (). Each private provider of special education or other non-LEA program shall complete a minimum of 3 comprehensive reports per year on each child with a disability enrolled in the program. {k) The reports required in Ed 1114.06 (g) shall: (1) Describe the child's progress toward meeting the IEP goals: (2) Include a record of attendance; (3) Be written in terminology understandable to the parent; and (4) Be provided to the sending LEA and the parent of the child. (I) Reports provided to parents shall be in the native language or other mode of communication used by the parent. with Lakeview School was not able to provide record of attendance, or progress report and there is no documentation that these reports were provided to sending LEA and the parent of the child. ‘Action Required: Lakeview School must provide evidence of implementing Ed 1114.06(g+i) for the two New Hampshire students from September 1, 2015. Evidence of Correction of Noncompliance Due: _| Evidence Recelved: March 26, 2015, Not yet received. Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘+ Required action: Lakeview School must provide evidence of implementing Ed 1114.06(g-I) for the two New Hampshire students from September 1, 2015. © Evidence reviewed during the Fe = Lakeview School provided NH student files to the monitoring team. The monitoring team was not able to locate a record of attendance in the progress report or a record of the progress reports being provided to the sending LEA and the parent of the child. Emergency Planning and Preparedness Ed 1114.21(a) Each private provider of special education or other non-LEA program shall have waiften Procedures for staff and children to follow in case of emergency. These procedures shall be developed with the assistance of state or local fire and safety personnel and shail include provisions for the evacuation of buildings and assignment of staff during emergencies. Lakeview Schoo! staff members did not follow first responder emergency procedures. ‘Action Required: Lakeview School must provide evidence of written procedures for staff and students to follow in case of emergency as well as evidence that staff have been informed and trained it these procedures. Evidence of Correction of Noncompliance Due: _| Evidence Received: March 26, 2015: Not yet received.‘Tina Trudel, Chief Operating Officer Lakeview Neurorenabiltaion Center March 11, 2015 Page 8 of 32 Review Status: ‘As of March 11, 2015, Lakeview School has not shown evidence of correction of, ‘the noncompliance. This area continues to be a finding of noncompliance. + Required action: Lakeview School must provide evidence of written procedures for staff and students to follow in case of emergency as well as evidence that staff have been informed and trained in these procedures. ° vi viewed durin ruary 26, 2015 on-site visit: ‘The monitoring team witnessed a first responder’s incident. When the monitoring team was moving from the white module to the brown building they came upon two Lakeview Schoo! staff members who were acting the role of fist responders reporting to. an emergency. The monitoring team watched the fist responders go within classrooms at the brown building and the first classroom of the white modular before finding out it was in the second classroom of the white modular questioning the teachers "is this where the emergency is?” Both first responders were unfamiliar with the location given when the fist responders call went out. A teacher was injured even though she was wearing protective gear ‘and a member of the monitoring team had to inform her to go take care of the injury. None of the responders attended to the injured staff member. There was no debriefing, The staff were unable to state a policy or procedure for how long they were to stay after the incident. The teacher was not given a change to collect themselves. A student had to leave the room because the incident was too overwhelming for them. There was an aide who was left with two students. None of the individuals involved in the incident could tell the monitoring team about a pre-incident protocol, during incident protocol or a post incident protocol. The NHDOE witnessed a student leave the brown building. Shortly after the teacher left her classroom, came to the outside door calling for the student. She called for first responders while watching the student walk up the hill. No Gide followed. During the visit the on-site the monitoring team was informed that this student has a one-to-one aide. The monitoring team saw no protocol in place to address the student's behavior prior to incidence, during the incident, or after the incident. The monitoring team observed a staff member with three or four fresh scratches on their face. When asked how that happened they said that they were working with a student and called for additional staff because "! was the trigger” and that the staff member removed themselves so that the student could de- escalate. They reported that they tumed around to see how the student was doing and that the student “got me.” When asked what process they follow when such incidents occur, they said they had to fil out an "IR to track behavior” ‘and file a “fist injury report". When asked if this was thei fist injury, they said no; they had been injured a few times, but that was just what the form was called, and they did not know why. When asked what else they were supposed to do. They said they were supposed to get checked by health services and that they ‘would do that later. The staff member reported that the student has bad days and that there was currently another staff working with the student.‘Tina Tridel, Chief Operating Officer Lakeview Neurorenabitation Center March 11, 2018 Page 9 of 32 Class Size Ed 1114.14 Class Size. Each private provider of special education or other non-LEA program shall conform to the requirements of Ed 1113.10 with respect to special education class sizes, teacher- student ratios, and the age range within each class, Ed 1113.10(e) The following shall apply to a self-contained special education class grades K-12: (8) On the junior and senior high school levels, children in self-contained classes shall have an age range of not more than 4 years and an academic range of not more than 5 years. Lakeview School had three classrooms with students ranging in age of more than four years. ‘Action Required: Lakeview School must reorganize classes to comply with this age range and provide evidence that this was accomplished. Evidence of Correction of Noncompliance Due: _| Evidence Received: March 26, 2015, Not yet received. Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction oF ‘the noncompliance. This area continues to be a finding of noncompliance. ‘+ Required action: Lakeview School must reorganize classes to comply with this age range and provide evidence that this was accomplished. © Evidence reviewed during the February 26, 2015 on-site visit: * Lakeview Schoo! staff and students reports ages of more than four years at the High Schoo! Program in four separate classrooms that were observed by the monitoring team: The ages of students in frst classroom visited were 16, 18 & 20. The second classroom had ages of 14, 16 & 20, The third—15, 19 & 20. The fourth—15, 15,15, 16 & 20. * The monitoring team was given an attendance roster. The roster identified that was a total of twenty-three students enrolled in the school. Two of the students were at their cabins per Health Services. Therefore there should have been ‘twenty-one students in the school. The monitoring team observed fourteen students in the High School and two students in the elementary school, totaling eighteen students accounted for. The monitoring team questioned the Director ‘of Education where the remaining five students were. The team was told that “they're around”. When questioned further, the Director of Education could not provide any further explanation as to where those students were. Physical Faciilies Ed 1114.16(a) Each private provider of special education or other non-LEA program shall ensure that the grounds and all structures on the grounds of the program are maintained in good repair and ore free from any danger to health or safety. Lakeview School's walkways had evidence of ice and snow. Lakeview School performed structure repair during a class. ‘Action Required: Lakeview School must provide evidence of how they comply with ensuring that the grounds and alll sructures on the grounds of the program are maintained in good repair and are free {from any danger to health or safety. Evidence of Correction of Noncompliance Due: | Evidence Received: March 26, 2015 Not yet received. Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. * Required action: Lakeview School must provide evidence of how they comply with ensuring that the grounds and all structures on the grounds of the program are maintained In good repair and are free from any danger to health or safety.‘Tina Trudel, Chief Operating Officer Lakeview Neurorenabiltation Centr ‘March 11, 2015, Page 10 of 32 o Evidence reviewed during the February 26, 2015 on-site visit: «The monitoring team observed a student in a wheelchair and other students with requiring mobilty support. Students frequently move in and out of buildings (residences, classrooms, and cafeteria). Walkways were not clear of ice and snow during this winter on-site visit. + The monitoring team observed the PE teacher was working with a student in the gym. While the teacher and student were exercising, another person in the room about two yards away from the teacher and student was on a ladder replacing celling files. One window was also boarded up with a piece of plywood. No staff could tell the monitoring team when the window was broken. Facilities and Location. Ed 1113.11 (d) The physical space used for classrooms and other insiructional programs and school activities for children with disabilities shall be of sufficient size to accommodate program modifications and accommodations necessary to implement the children’s IEPs and to provide for ail other learning activities. Lakeview School provided minimal instruction to students. There appeared to be distractions from other students which interfered with the provision of instruction due to limited space in the classrooms to accommodate students’ needs. ‘Action Required: Lakeview School must provide evidence of how they comply with Ed 1113.11(d). Evidence of Correction of Noncompliance Due: | Evidence Received: March 26, 2015 Not yet received. Review Status: | As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompfance. Required action: Lakeview School must provide evidence of how they comply with Ed 1113.11(d) © Evidence revi during the February 26, 201 = The monitoring team observed classrooms with limited space to accommodate students’ needs, One staff reported that their classroom was crowded with the recent addition of a fifth student and that space and student dynamics caused inleruption of class routines. Notice and Record-Keeping Requirements RSA 126-07 IV. Whenever a facility o” school employee has intentional physical contact with a child which is in response to a child's aggression, misconduct, or disruptive behavior, a representative of the school or facility shall make reasonable efforts to promptiy nofify the child's parent or guardian. Such notification shall be made no later than the time of the retum of the child to the parent or guardian ‘or the end of the business day, whichever is earlier. Notification shall be made in a manner calculated to give the parent or guardian actual notice of the incident at the earliest practicable time. V. In any case requiring nofification under paragraph IV, the school or facility shall, within 5 business days of the occurrence, prepare a written description of the incident. Lakeview Schoo! did not provide evidence of written parent nofification of the documented six restraints of 60 seconds of less in a New Hampshire student's fle. ‘Action Required: Lakeview School must show evidence that there is a written procedure for ‘complying with RSA 126:U:7, evidence that staff was informed and trained in the procedure as well as any forms used to implement this statute.‘Tina Trudel, Chet Operating Officer Lakeview Nourorehabiltaion Conter March 11, 2018 Page 11 of 32 Evidence of Correction of Noncompliance Due: _| Evidence Received: March 26, 2015 Not yet received. Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. + Required action: Lakeview School must show evidence that there Is a written procedure for complying with RSA 126:U:7, evidence that staff was informed and trained in the procedure as well as any forms used to implement this statute during the Fe 2015 onsite + Lakeview Schoo! did not provide evidence of written parent notification of the documented six restraints of 60 seconds or less in a New Hampshire student's file. Copies of the IEP ond Evidence of Implementation Ed 1109.04(b) The LEA shall maintain written evidence documenting implementation of the IEP, including, but not limited to, the following: (1) Allspecial education and related services provided; (2) Any supplementary aids and services provided; (3) Programs modifications made; and (4) Supports provided for schoo! personnel implementing the IEP. Lakeview Schoo! did not provide evidence of implementation of IEPs. Lakeview School provided alist of staff assignments for teacher assistant/education aide student assignments for implementing students’ IEPs. The monitoring team observed one student without their one-to-one aide and one student with their teacher acting in that capacity. ‘Action Required: Lakeview School must provide evidence of Ed 1109(b) for the New Hampshire students. Evidence of Correction of Noncompllance Due: _| Evidence Received: March 26, 2015 Not yet received. Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. * Required action: Lakeview School must provide evidence of Ed 1109(b) for the New Hampshire students. © Evidence reviewed during the February 26, 2015 on-site visit: = The monitoring team observed students without one-on-one staf assignments and heard the page for additional staff to immediately report to the high school building. Lakeview School staff did not appear to know where they needed to be or with whom they were working. The monitoring team questioned a residential aide that anived in a classroom while they were there, and the cide stated that they were informed to report to the classroom fifteen minutes ago (about the time the moritoring team arrived).The staff member who deployed the aides assured the monitoring team that they were well staffed, though was later seen acting as an aide in gym class. Another staff member reported that eight staff members were on leave and that the school was understaffed today. Lakeview School created a list of staff/student assignments after the monitoring team requested one; reporting that the list changes daily. The aide's list included the behavior specialist, the vocational high school teacher, residential counselors, the Assistant Director of Youth Services, and a staff member from the Young Adult Program. A consistent schedule could not be discemed, nor whether staff received the training or support needed to implement their students’ IEPs and behavior intervention plans. A staff member in the school office told members of the monitoring team that they were a one-to-one aide and they did work with a specific student but this day wasn't their day in the‘Tina Trude, Chief Operating Offcor Lakeview Neurocehabitaion Center Maret 11, 2015; Page 120f 32 rotation. They later told other members of the monitoring team they did not have a stucent this day due to being injured and being on light-duty. Program Requirements: Communication Ed 1114,05(h) A private provider of special education or other non-LEA program shall have an’ established system of routine communication among all staff members of the program who provide direct services to a child, including both instructional and residential services. All staff members involved in providing direct services to a child with a disability shall participate in the process of planning for that child and shall know the contents of that child's IEP and all other reports and evaluations, as appropriate to their role and responsibilities. Lakeview School staff members were not able to account for all students. ‘Action Required: Lakeview Schoo must provide evidence of the established system of routine ‘communications among staff. In addition Lakeview School must provide evidence of how staff was informed and trained in the established process as well as any forms used to support this ‘administrative rule. Lakeview School must provide the schedule of classes and teachers from ‘September 1, 2014 for both the elementary and high school programs. Evidence of Correction of Noncompliance Due: | Evidence Receive March 26, 2015 Not yet received. Review Status: As of March 11, 2015, Lakeview Schoo! has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘+ Required action: Lakeview School must provide evidence of the established system of routine ‘communications among staff. In addition Lakeview School must provide evidence of how staff was informed and trained in the established process as well as any forms used to support this administrative rule. © Evidence reviewed during the February 26, 2015 on-site visit ‘= The monitoring team asked how student absences are reported. Lakeview ‘School staff responded that they think absences are reported fo homeroom teachers, and that there is no system for reporting absences to subject teachers. «Required action: Lakeview School must provide the schedule of classes and teachers from September 1, 2014 for both the elementary and high school programs. ° nce reviewed the Februar nesite visit: ‘= The monitoring team asked for current schedules. Lakeview School provided different versions of proposed schedules. Teachers did not have current schedules and report that classes change constantly. * The Director of Education told the monitoring team that recently they had ‘added a Social Skills course from 11:30-12:00 daily. The monitoring team saw no evidence of this course during the on-site. Additional Findings of Noncompliance determined on January 26, 2015 New Rules for the Education of Children with Disabilities Lakeview Schools Policies and Procedures reference NH Rules June 2008. The New Hampshire Rules for the Education of Children with Disabilities were amended as of December 1, 2010 and again amended as of May 15, 2014. ‘Action Required: Lakeview School must develop written policies that reference the NH Rules amended May 15, 2014. Lakeview Schoo!'s updated, board approved Special Education Policies and Procedures must be provided fo the Bureau withi cof the his letter (Jan 2015) Evidence of Correction of Noncompliance Due: | Evidence Recelved: January 21, 2015; March 26, 2015: verified os board approved on January 27, 2015_|Tina Trudel, Chief Operating Officer Lakeview Neurorehabiltaion Center March 11, 2015 Page 13 of 32 Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. + Required action: Lakeview Schoo! must develop written policies that reference the NH Rules ‘amended May 15, 2014, © Evidence submitted by Lakeview School January 21, 2015 and verified as board ‘gpproved on January 27, 2015 to address the required action: "= Asection of Lakeview school's Policies and Procedures references the NH Rules June 2008. © Evidence reviewed duting the February 26, 2015 on-site vist: * No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards comection of noncompliance. When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought fo the on-site. New Hampshire Rules for the Education of Children with Disabilities P.L. 111-256, Rosa's Law, Mental Retardation to intellectual Disability, effective October 5, 2010. Lakeview Schoo!'s Policies and Procedures contain the term “Mental Retardation" ‘Action Required: Lakeview School must develop written policies that use the term "Intellectual Disability". Lakeview School's updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of t Evidence of Correction of Noncompliance Due: _| Evidence Received: January 21, 2015; March 26, 2015, verified as board approved on January 27, 2015: Review Status: _ As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. * Required action: : Lakeview School must develop written policies that use the term “Intellectual Disability”. © Evidence submitted by Lakeview Schoo! January 21, 2015 and vetifed as board Jan iddress the ‘ * Asection of Lakeview school's Policies and Procedures uses the term “Mental Retardation” © Evidence reviewed during the February 26, 2015 on-site visit: = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. ‘When NHDOE asked atiout progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought to the on-site.‘Tina Trudel, Chi Operating Offcer Lakeview Nouroreabittaon Center ‘March 11,2015 Page 1401 32 Behavioral interventions, Ed 111407{¢) A private facility or other non-district program shall not employ any measure which is ‘aversive or depriving in nature or which subjects a child with a disability enrolled in that program to humiliation or unsupervised confinement or to abuse or neglect as defined in RSA 169-C, the Child Protection Act, or which deprives the child of basic necessities such as nutrition, clothing, communication, or contact with parents, so as to endanger the child's mental, emotional, or physical health consistent with Ed. 1114.07. Lakeview School's Policies and Procedures state “The Lakeview School ensures that all crisis or ‘emergency intervention procedures that include aversive behavior interventions are included in the students’ IEP's and comply with Ed 1114.07 except as detailed in Ed 1114.09." Ed 1114.09s RESERVED in the current NH Rules as the aversive behavior language was removed in May 2014. Laxeview ‘School's Policies and Procedures cannot use aversive behavior interventions. ‘Action Required: Lakeview School must develop written policies that comply with Ed 1114.07(c). Lakeview School's updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of this letter [January 26, 2015} Evidence of Correction of Noncompllance Due: | Evidence Received: January 21, 2015; March 26, 2015 verified as board approved on January 27, 2015: Review Status: _ As of January 27, 2015 evidence has been submitted that resolves this finding. © Requied action: Lakeview School's Policies and Procedures cannot use aversive behavior Interventions. © Evidence submitted by Lakevi ni ‘and verified as 90ard ‘approved on January 27, 2015 to address the reauired action: = Lakeview School's Policies and Procedures no longer reference Ed 1114.09 or aversive behavior interventions. New Hampshire Rules for fhe Education of Children with Disabilities Ed 1126,02(6] The department shall approve public and non-public programs for children with disabilities through a monitoring process, including but not limited to on-site visi(s) and examination of written documentation, by reviewing the following: (3) Policies and procedures, including: ‘a. Procedures for handling confidential information; b. Due process guarantees; c. Least restrictive environment processes; d. Child find activities; e. Non-dscriminatory testing practices; ond (IEPs; Lakeview School's Policies and Procedures do not mention or explain due process or non- discriminatory testing practices. ‘Action Required: Lakeview School must develop waiffen policies that address Ed 1126.02(0)(3) Lakeview School's updated, board approved Special Education Policies and Procedures must be provided fo the Bureau jonths of the date of ths letter (J H Evidence of Correction of Noncompliance Due: _| Evidence Received: January 21, 2015; March 26, 2015 verified as board approved on January 27, 2015 Review Status: As of March 11, 2015, Lakeview School has nat shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. + Requited action: Lakeview School must develop written policies that address Ed 1126.02(b)(3) ‘0 Evidence submitted by Lakeview School January 21, 2015 and verified as board ‘approved on January 27, 2015 to address the required action:‘Tina Trudal, Cot Operating Oficor Lakeview Neurrehabiliaion Cantar March 11, 2015, Page 150132 = Lakeview School's Policies and Procedures do not mention or explain Due process guarantees or Non-discriminatory testing practices. © Evidence revi ‘ebru i vi = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought to the on-site. Responsibilities of Private Providers of Special Education or Other Non-LEA Programs in the of IEPs Ed 1114,06(a) Each private provider of special education or other non-LEA program shall in ail matters conceming possible changes and/or modifications in the identification, evaluation, development and/or revision of an IEP, or changes in placement of a child with a disability, contact the sending school district for the purpose of initiating the process for changing any of the above in compliance with Ed 1109.05. (c) Each private faciity or other non-district program shall provide all transportation required for the implementation of any IEP, or portion of any IEP, which the program has agreed to implement. (d) The private facility or other non-district program shall provide transportation in accordance with Ed 1109.02. (e} All vehicles providing transportation for students shail be insured as provided in Ed 1114.19(c)(2) and 1129.08(ak).. (f) Daily lesson plans shall be clear, concise, and reflective of the IEP goals for each child. They shall reflect any staff input and related reports and evaluations provided by the agencies responsible for the student's education and welfare. (i) Ifa private provider of special education or other non-LEA program determines that any child with @ disabilty placed at the facility or program is not making progress toward meeting his or her IEP {goals at the rate anticipated, the facility or program shall immediately contact the LEA for the purpose of reviewing the IEP and considering modifications. Lakeview School's Policies and Procedures do not contain descriptions of any of the preceding. ‘Action Required: Lakeview School must develop written policies that address Ed 1114.06(a). (c)-(). (- Lakeview School's updated, board approved Special Education Policies and Procedures must be rovided to the Bureau within 2 tt f Evidence of Correction of Noncompliance Due: | Evidence Received: January 21. 2015; March 26, 2015, verified as board approved on January 27, 2015, Review Status: As of March 11, 2015, Lakeview Schoo! has nat shown evidence of corection of the noncompliance. This area continues to be a finding of noncompliance. * Required action: Lakeview School must develop written policies that address Ed 1114.06(a), {e)-(9, 0. © Evidence submitted by Lakeview School January 21, 2015 and verified as board approve address the required action: = Lakeview School's Policies and Procedures do not contain written procedures regarding Ed 1114.06a}, (c)-() (i). ° ic ie during the 26, 201 ite visit: * No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance.“Tina Trudel, Chet Operating Ocar Lakeview Neurochabiltation Center March 11, 2015, Page 18 of 32 When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE krought to the on-site. Physical Faciifies Ed 1114.16(d) Each private provider of special education or other non-LEA program shall have written procedures to protect children from hazards such as: (1) The presence of asbestos; (2) The presence of lead paint; (3) Storage of hazardous materials; (4) Garbage disposal; (5) Vermin infestatio (6) Storage of food: (7) Storage of medicines; and (8) Any unsafe access to electrical, plumbing, and heating systems. (e) A private facility or other non-LEA program shall have a policy that ensures that bathrooms, Classrooms, and other areas where children spend time at the facility, are regularly cleaned to maintain health and sanitation. Lakeview Schoo''s Policies and Procedures refer to Lakeview Neurorehabiiitation Environmental Management Policy and Procedures Section 7 however that policy was not included with the Lakeview Schoo''s Policies and Procedures. For Ed 1114.16(e) Lakeview Schoo!'s policies and procedures state they have a policy but no description of poicy is provided. ‘Action Required: Lakeview School must develop written polices that address Ed 1114.16(d)-(e). Lakeview School's updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of this letter [January 26, 2015) Evidence of Correction of Noncompliance Due: _| Evidence Received: January 21, 2015; March 26, 2015, verified os board approved on January 27, 2015 Review Stafus: _ As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘+ Required action: Lakeview Schoo! must develop written policies that addrt Ed 1114.16(d)-(e). 0 Evidence submitted by Lakeview School January 21, 2015 and verified as board roved on 27.2015 10 ss the required : ‘= Lakeview School's Policies and Procedures refer to policies not included in the submitted documents. © Evidence reviewed during the February 26, 2015 on-site visit: = No additional evidence was provided nor did the monitoring team observe. evidence of progress being made towards correction of noncompliance. When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought to the on-site.‘Tina Trudel, Chief Operating Officer Lakeview Neurorenabiltation Center March 14,2015 Page 17 of 32 Health and Medical Care Ed 1114.18(a) Each private provider of special education or other non-LEA program shall have written procedures to ensure that children with disabilities receive prompt and competent medical attention in the event of injury or ness while at the program or while participating in any program or activity while in the custody of the program, (c} Each private provider of special education or other non-LEA program shall have formulated wtten policies and procedures regarding the use and administration of medicine to children in compliance with state law and rules. Medication shall be dispensed only under medical order. Lakeview Schoo''s Policies and Procedures “ensure that it has a written procedure" but does not provide a description of what that procedure is. ‘Action Required: Lakeview School must develop written policies that address Ed 1114.18 (a) and (c). Lakeview School's updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of this letter (January 26, 2015) Evidence of Correction of Noncompliance Due: | Evidence Recelved: January 21, 2015; March 26, 2015, verified as board approved on January 27, 2015, Review Status: As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area confinues to be a finding of noncompliance. © Required action: Lakeview School must develop written policies that address Ed 1114.18 (a) and (c). © Evidence submitted by Lakeview School January 21, 2015 and verified as board 7, tion: ‘© Lakeview School's Policies and Procedures refer to policies not included in the submitted documents. © Evidence reviewed during the February 24, 2015 on-site visit: "No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards corection of noncompliance. When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought to the on-site. Photography and Audio or Audio-Visual Recording Ed 1114.20(a) Each private provider of special education or other non-LEA program shall have written Policies and procedures regarding the photographing and audio or audio-visual recordings of children in care. {b) The written consent of the child's parent shall be obtained before the child is photographed or Tecorded. Lakeview Schoo''s Policies and Procedures “ensure that it has a written procedure" but does not provide a description of what that procedure is. ‘Action Required: Lakeview School must develop writfen policies that address Ed 1114.20 (a) and (b). Lakeview School's updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of this letter (January 26, 2015) Evidence of Correction of Noncompliance Due: | Evidence Recelved: January 21, 2015; March 26, 2015, verified as board approved on January 27, 2015 Review Status: As of March 11, 2015, Lakeview School has nat shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance.‘Tina Trude, Chiof Operating Offcer Lakeview Nourorehabiliaton Center ‘March 1, 2015 Page 186f 32 © Required action: Lakeview School must develop written policies that address Ed 1114.20 (a) and (b). ° mitted by Lakeview School J 15 and verified as board approved on January 27, 2015 to address the reauired action: = Lakeview School's Policies and Procedures refer to policies not included in the submitted documents. Lakeview School's Policies and Procedures do not contain a written procedure. © Evidence reviewed ci 15 on-site visit: = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12,2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought to the on-site. Emergency Planning and Preparedness Ed 1114.21(a) Each private provider of special education or other non-LEA program shall have written procedures for staff and children to follow in case of emergency. These procedures shall be developed with the assistance of state or local fire and safety personnel and shall include provisions for the evacuation of buildings and assignment of staff during emergencies. Lakeview School's Policies and Procedures do not provide a description of the procedure. ‘Action Required: Lakeview School must develop written policies that address Ed 1114.21(a) Lakeview ‘School's updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of this letter [January 26, 2015) Evidence of Correction of Noncompliance Due: _| Evidence Received: January 21, 2015; March 26, 2015 verified as board approved on January 27, 2015 Review Status: _ AS of March 11, 2015, Lakeview School has not shown evidence of correction of the. noncompliance. This area continues to be a finding of noncompliance: ¢ Required action: Lakeview School must develop written policies thal address Ed 1114.21(a) ° Evi ipmitted by Lakeview Scho verified as approved on January 27, 2015 to adress the required action: = Lakeview School's Policies and Procedures do not contain a written procedure. Lakeview Schoo!'s Policies and Procedures refer to policies not included in the submitted documents. ° Evi viewed during the February 26, ite vist: ‘= No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. When NHDOE asked about progress being made the Director of Education provided Policies and Procedures with December 12, 2014 Board Approval not the Policies and Procedures with January 27, 2015 Board Approval. The Director of Education requested a copy of the Policies and Procedures with January 27, 2015 Board Approval that the NHDOE brought to the on-site.Tina Trudel, Chief Operating Oficor Lakeview Neurorehabitaion Centor March 11,2015 Page 19.032 Additional Finding of Noncompliance determined on December 29, 2014 ‘Child Care. Ed 1114.17{a) The day care and residential components of all private providers of special education cor other non-LEA programs shall meet all applicable federal, state, and local rules governing the day and residential care of children with disabilities. Lakeview School is operating an unlicensed residential component to their special education programs. ‘Action Required: Lakeview must submit a current license immediately to correct this area of noncompliance. Evidence of Correction of Noncompliance Due: _| Evidence Recelved: February 20, 2015 immediately Evidence of correction of noncompliance was not provided within the established timeline. Review Status: _As of March 11, 2015 evidence has been submitfed that resolves this finding. ‘* Required action: Submit current residential license © Evidence submitted by Lakeview School on December 29, 2014 to address the required ‘action: = No evidence submitted © Evidence submitted by Lakeview School on January 21, 2015 to address the required action: No evidence submitted © Evidence received from DHHS on February 20, 2015 ‘© The NHDOE received a letter from DHHS dated February 20, 2015, that made references to RSA 541-A:30, indicating Lakeview School's residential icense continues to be valid until such time as the Health Facility Licensing Unit issues the renewal license. Additional Finding of Noncompliance determined on December 22, 2014 Program Approval of Public and Nen-Fublic Programs Ed 1126.03(a) All programs operated by LEAS, public academies, private providers of special education, public agencies, and other non-LEA programs shall be approved, utilizing the New Hampshire special education approval process in Ed 1126.02 as determined by the Bureau of Special Education in the department. Lakeview School is operating an additional program, Interim Alternative Placement, which is not approved by the NHDOE. ‘Action Required: Lakeview School must immediately stop operating the Interim Alfemative Placement Program. Students currently participating in the Interim Altemative Placement Program must be transitioned to an appropriate program by the sending LEA. Lakeview School must provide evidence within forty-five (45) days (letter dated December 22, 2014) that placement meetings were held and students were removed from this placement. Evidence of Correction of Noncompliance Due: _| Evidence Received: February 5, 2015 December 30, 2014 Review Status: As of January 7, 2015 evidence has been submitted that resolves this finding. ‘* Required action: Lakeview School must provide evidence within forty-five (45) days that placement meetings were held and students were removed from this placement. © Evidence submitted by Lakeview School on December 30, 2014 to address the required action:‘Tina Trude, Chief Operating Officer Lakeview Neurcehabiltation Center March 11,2015 Page 20 032 + Aletter was received December 30, 2014 from Lakeview Schoo! that stated the Interim Altemative Placement is not a program at Lakeview School and there are no students participating. Interim Altemative Placement Program has been removed from all marketing materials. Additional Finding of Noncompliance determined on December 19, 2014 ‘of Public and Non-Publle Programs: Ed 1126.03(a) All programs operated by LEAs, public academies, private providers of special education, public agencies, and other non-LEA programs shall be approved, utilizing the New Hampshire special education approval process in Ed 1126.02 as determined by the Bureau of Special Education in the department. Lakeview School is operating an additional program, a vocational skills classroom, which is not approved by the NHDOE. ‘Action Required: Lakeview School must immediately stop operating the vocational ski classroom. Students currently participating in the vocational skills classroom must be ‘ransitioned to an ‘appropriate program by the sending LEA. The Bureau will review evidence of the corrective action at g wer Evidence of Correction of Noncompliance Due: _| Evidence Received: at a subsequent on-site visit. February 26, 2015 subsequent on-site visit. Evidence of correction of noncompliance was not provided within the established timeline. Review Status: _As of March 11, 2075, Lakeview Schoo! has not shown evidence of correction of the noncompliance. This area confinues to be a finding of noncompliance. © Required action: Lakeview School must immediately stop operating the vocational skills classroom. © Evidence reviewed during the February 24, 2015 on-site vist: * No adcitional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. ‘© Required action: Students currently participating in the vocational skills classroom must be transitioned to an appropriate program by the sending LEA © Evidence reviewed during the February 26, 2015 on-site vist: + No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance‘Tina Trudal, Chief Operating Officer Lakeview Neurorehabillaton Center March 11,2015 Page 2 of 32 Findings of Noncompliance (Written notification to Lakeview School on November 12, 2014) Program Approval of Public and Nen-Public Programs Ed 1126.03(a) All programs operated by LEAS, public academies, private providers of special education, public agencies, and other non-LEA programs shall be approved, utilzing the New Hampshire special education approval process in Ed 1126.02 as determined by the Bureau of Special Education in the department. Lakeview School is operating an additional program, High School Life Skill, which is not approved by the NHDOE. ‘Action Required: Lakeview School must immediately stop operating the Life Skil Program. Students currently participating in the Life Skils Program must be transitioned to an appropriate program by the sending LEA. The Bureau will review evidence of the corrective action at a subsequent on-site visit Evidence of Correction of Noncompliance Due: _| Evidence Received: December 16, 2014, at a subsequent on-site visit. February 26, 2015 subsequent onsite visit Evidence of correction of all instances of noncompliance was not provided within the established timeline. Review Status: As of January 26, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘As of March 11, 2015, Lokeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. + Required action: Lakeview School must immediately stop operating the Life Skils program © Evidence reviewed during the Fi vi * During the February 26, 2015 on-site the monitoring team overheard the director of education informing staff not to call the white modular building the Life Skis Program. Lakeview School did not provide any evidence of how this program had been incorporated in to the high school program. Lakeview School gave no description of how this would be included in the high school program. The Director of Education informed the monitoring team that two students were temoved from the brown building to be put into the white modular building {known previousy as the Life Skils program). Staff reported that the transition “has been okay" though, for some students, it has been difficult. ‘* Required action: Students currently participating in the Life Skills Program must be transitioned to an appropriate program by the sending LEA © Evidence submitted by Lakeview School on Decer ined action * Lakeview School submitted a spreadsheet listing students, Parent Guardian Names, Parent Phone, Parent Email, LEA Contact Name, LEA Phone, LEA Email, Teacher and Notes. Many of the notes lst "Left Message. No call back at this time”. These notes do not indicate that all students have been transitioned to «n appropriate program by the encing LEA ° Evi ew School on January 21, 2015 t the reaui actior + No evidence submitted. © Evidence reviewed during the February 26, 2015 on-site visit: ‘No addifional evidence provided. The NHDOE was not given a description of how this program was integrated into the High School program.‘Tina Trudel, Chief Operating Offcer Lakeview Neurorehabiltaton Center March 11, 2015 Page 22 of 32 ‘Administration. Ed 1114.04(a)-(g) outiines the mandated written policies for a private provider of special education. Lokeview Schoa! did not show evidence of witten policies that comply with Ed 114.04 (a}-(g). ‘Action Required: Lakeview School must develop written policies that address Ed 1114.04 (a)-(g). Lakeview Schoo!'s updated, board approved Special Education Policies and Procedures must be provided to the Bureau within 2 months of the date of this letter (November 14, 2014). Also provide the agency's organization chart. Evidence of Correction of Noncompliance Due: _ | Evidence Received: December 16, 2014, January January 14, 2015 27, 2015. Evidence of correction of noncompliance for Ed 1114,04(a) and Ed 1114,04{b) continues to be noncompliant. Evidence of correction of noncompliance was not provided within the established timeline. Review Status: AS of January 26, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. * Required action: develop written policies that address Ed 1114.04 (a)-(a). ° Lakeview School on December 14, 2014 to address the required action: = Lakeview Schoo!'s Policies and Procedures, adopted by the Board of Directors effective December 12, 2014 were received on December 16, 2014. = The evidence provided does not demonstrate fiscal accountability through regular recording of its finances and an annual external audit consistent with the requirements in Ed 1114.04(a) + The review of Lakeview Schoo!'s policies and procedures shows noncompliance with the requirements of IDEA and RSA 186-C as stated in Ed 1114.04(b} + The review of Lakeview's policies and procedures shows compliance with Ed 1114.04{c) + The review of Lakeview's policies and procedures shows compliance with Ed 1114.04(d) + The review of Lakeview's policies and procedures shows compliance with Ed 1114.04(e) + The review of Lakeview's policies and procedures shows compliance with Ed 1114041) * The Bureau of Credentialing confirms Lakeview Schoo! has a professional development plan good through June 30, 2016 in compliance with Ed 1114.04(g). ° itt akevi Lon required action = Lakeview Schools’ Policies and Procedures that were submitted on January 21, 2015 did not have evidence of board approval. These policies and procedures were not reviewed for evidence of correction of noncompliance. © Evidence submitted by Lakeview Schoo! January 21, 2015 and verified as board roved on January 27, 2015 to a jted action: = The review of Lakeview Schoo''s policies and procedures shows noncompliance with the requirements of IDEA and RSA 186-C as stated in Ed 1114.04(b}. © Evidence revie iui ite visit = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance.Tina Trudel, Chief Operating Officer Lakeview Neurorenabitaion Conter March 11, 2015; Page 23 of 32 * Required action: Submit the agency's organization chart © Evidence submitted by Lakeview School on December 16, 2014 to address the reauited action; + No evidence submitted o Evidence submitted by Lakeview School on January 21, 2015 to address the required action: = No evidence submitted * No additional evidence was provided nor did the monitoring team observe: evidence of progress being made towards correction of noncompliance. Limiting the Use of Child Restraint Practices in Schools and Treatment Facilities: RSA 1262U Limiting the Use of Child Restraint Practices in Schools and Treatment Facilities Lakeview Schoo! did not provide evidence of complying with RSA 126:U ‘Action Required: Lakeview School must comply by having all the required writien policies and nofice ‘and record keeping requirements. Lakeview School's updated, board approved Policies and Procedures for implementing RSA 126: must be provided to the Bureau within 2 months of the date of this letter (November 14, 2014) Evidence of Correction of Noncompliance Due: _| Evidence Received: December 16, 2014, January January 14,2015 27, 2015, February 13, 2015. Evidence of correction of all instances of noncompliance was not provided within the established timeline. Review Status: As of January 26, 2015, Lakeview School has nat shown evidence of conection of ‘the noncompliance. This area continues to be a finding of noncompliance. As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. * Required action: Submit updated, board approved policies and procedures for implementing RSA 126:0 © Evidence submit kevi 14 to address the require: ‘action: = Lakeview Schoo''s Policies and Procedures, adopted by the Board of Directors effective December 12, 2014 were received on December 16, 2014. Lakeview Schoo!'s Policies and Procedures are not in compliance with RSA 126:U. The physical management component advised the use of restraints if "any other behavior management intervention delineated in the BIP have not had a calming effect on the potentially harmful behavior". This matter has been referred to the Division of Program Support, Education Investigation. © Evidence submitted by Lakeview School on January 21, 2015 to address the required action: = Lakeview Schools’ Policies and Procedures that were submitted on January 21, 2015 did not have evidence of board approval. These policies and procedures were not reviewed for evidence of correction of noncompliance. © Evidence submitted by Lakeview School January 21, 2015 and verified as board roved on January 27, 2015 to addres i ion: * Lakeview Schoo''s Policies and Procedures are not in compliance with RSA 126:U. The physical management component advised the use of restraints if “any other behavior management intervention delineated in the BIP have not had a calming effect on the potentially harmful behavior". © Evidence submit vi a " * The NHDOE was informed that Lakeview School had spoken with Rich Farrell, Investigator for Educator Misconduct, on February 12, 2015 regarding the‘Tina Trudel, Chief Operating Officer Lakeview Neurorenabiltation Center Maret 14,2015; Page 24 of 32 revision of Lakeview School 's behavioral and restraint policies and procedures. Dr. Trudel informed the NHDOE that Lakeview School intends to resubmit this information within a week of February 12, 2015. Rich Farrell confirmed that Lakeview had not followed up with him, nor has the NHDOE received documentation. ° viewed during the February 26, 201 visi No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. Program Requirements: Curiculum Ed 1114.05(g) In each private provider of special education or other non-LEA program, all children with disabilfies shall have access to equal educational opportunities within their programs and ‘access to and ability to progress in the general curriculum as required under 34 CFR 300.320. The curriculum labelled 2008-2009 Program of Studies does not represent a general curriculum. ‘Action Required: Corrective Action: Lakeview School must develop a cumiculum for the grades 1-12. The curiculum must be provided fo the Bureau within 2 mont this letter (Nove 14 Evidence of Correction of Noncompliance Due: | Evidence Received: December 16, 2014, January 14, 2015 February 26, 2015 subsequent on-site visit. Evidence of correction of noncompliance was not provided within the established timeline. Review Salus. As of January 26, 2015, Lakeview Schoo! has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘AS of March 11, 2015, Lakeview Schoo! has not shown evidence of correction of the noncompliance, This area continues to be a fincing of noncompliance. ‘+ Required action: Submit Lakeview School's curriculum for grades 1-12 ‘© Evidence submitted by Lakeview School on December 16, 2014 to address the required action: = Lakeview School's Curriculum for grades K-12 as received on December 16, 2014. Provided in the documents were the Common Core Standards and strands for each content area. This is not a curriculum. Cuniculum, as defined by Ed 1102.01(aa) means all of the courses and other educational opportunities offered by the responsible local education agency. * During the January 14, 2015 phone discussion the NHDOE asked for a list of high school courses. As of January 26, 2015 there is no evidence of high schoo! course work for the completion of a diploma. * During the phone discussion on January 14, 2015 it was discussed that the Bureau would verity Lakeview School's curriculum for grades 1-12 at a subsequent on-site visit. © Evidence revi it I: + The monitoring team requested the curriculum which was currently being implemented. The Director of Education provided K-12 Math and Language Arts curriculum binders (red-spine binders), and notified the monitoring team that this curiculum was being developed. Although provided for our review, given that they were not complete, approved, or being implemented we were unable to review these for evidence of correction of noncompliance. + While reviewing the binders, the monitoring team was informed that there was another curiculum in a large blue binder. This was given to the monitoring team to review. The Director of Education and Chief Operating Officer stated this was the curriculum that was completed, approved, and currently being implemented. This fst section of this curriculum included an overview and a program description for Grades 2-8, English Language Arts, Mathematics,‘Tina Trudel, Chief Operating Ofcar Lakeviow Nourorehabiltation Center Mareh 11, 2018, Page 25 of 32 Physical Education, Social Studies, and Technology Education listed. The next section took each subject area and provided further clarification and information for each of subjects. However the format for these sections was not consistent. For example some subject areas included Program Goals where others did not, some subject areas included a syllabus where other did not, some subject areas included texts and resources where others did not and some subject areas included copies of the New Hampshire Curricuium Frameworks charts for grades K-8 where others included charts for grades K-12 for the elementary curriculum. Lakeview School's elementary curriculum provided to the monitoring team in the blue binder was lacking an arts education, and a health education curiculum, Although they had technology education listed in the overview, the second section it was filed computer education and the program being Used was a pubiication from 2004. ‘* Scope and Sequence for each section of the curriculum provided contained a bulleted list of the NH Curriculum Frameworks and did not contain units of study or grade levels or sequences in which these would be implemented. Lakeview School's high school curiculum provided to the monitoring team in the blue binder was set up much the same as the elementary curiculum. There was an overview with course offerings for the following subjects: English Language Arts, Family Consumer Sciences, Mathematics, Physical Education, Science, Social Studies, and Technology Education. ‘+ For English Language Arts Lakeview Schoo!’s curiculum contains four courses, however according to Ed 306 Table 306-1 Lakeview School is required to offer six English courses. According to Ed 306 Table 306-3 students are required to eam four English credits in order to graduate. + Nowhere in the curriculum does it ist the number of credits earned per ‘course for any of the courses provided. ‘+ For Family and Consumer Science Lakeview School curriculum contains ‘one course for students in grades 9-12. According to Table Ed 306 306-1 schools are required fo offer three courses in Family and Consumer Science. * Students are required to have six credits in open electives according to Ed 306 Table 306-3. Lakeview School's curriculum contains one open elective course. * For Mathematics Lakeview School's curriculum contains three courses; ‘according to Ed 306 Table 306-1 Lakeview School is required to offer six Mathematics courses. According to Ed 306 Table 306-3 students are required to eam three Mathematics credits that encompass algebra mathematical modeling, statists and probability, complex applications of measurement, applied geometry, graphical presentation and interpretation, statistics and data analysis in order to graduate. ‘+ For Physical Education, Lakeview Schoo!'s curriculum contains one course for grades 9-12. This course is tiled Adaptive Physical Education. There was no evidence that Lakeview School is offering a regular high school physical education course. According to Ed 306 Table 30-1 Lakeview School is required to offer two courses in Physical Education. ‘According to Ed 306 Table 306.3 students are required to eam one credit to graduate. + For Science, Lakeview Schoo!'s curriculum contains three courses; ‘according to Ed 306 Table 306-1 Lakeview School is required to offer five courses in Science.‘Tina Trude, Chief Operating Officer Lakeview Nourorehabillaton Center March 11, 2015 Page 28 of 32 ‘+ ForSocial Studies, Lakeview Schools’ curiculum contains four courses; according fo Ed 306 Table 306-1 Lakeview School is required to offer five courses in Social Studies. According to Ed 306 Table 306-3 students are required to eam one credit in US and NH History, one half credit in US ‘and NH Govemment/Civics, one half credit in Economics, including personal finance, and one half credit in Word History, Global Studies, or Geography. * ForTechnology Education, Lakeview Schools’ curriculum contains two Courses one of which is not a Technology Education course; according to Ed 306 Table 306-1 Lakeview School is required to offer four courses. «The overview section in the Lakeview School's curriculum does not contain an overview for Arts Education however there is a course listing entitled Art 1 that students can take for one credit. It includes course description, goals and objectives, a topic outline, and assessments. ‘According to Ed 306 Table 306-1 Lakeview School s required to offer three courses in Arts Education. * Lakeview Schools’ curriculum did not provide courses for any of the following required courses per Ed 306 Table 306-1 and Table 306-3: Health Education, Business Education, and World Languages. Lakeview School is approved for grades 1-8 & 9-12. The curriculum in the blue binder started at grade 2, although, the Lakeview School program approval states that they will accept 1s graders. There was not evidence of a 1 grade curiculum. The NHDOE was given a third document, "Curiculum Guide, January 2015", which gave an overview of the process for curicuium development. This guide was the Lakeview Schoo!'s internal process for developing curriculum. The Curriculum Guide references three appendices; implementation Action Plan 2014-15, English and Language Arts (K-12) Curriculum, and Mathematics (K-12) Curriculum. These appendices were not included in the Curiculum Guide. The NHDOE is uncertain why this was provided since it does not shoe evidence of a curiculum. Upon the monitoring team's request for altemative cuniculum, the only evidence provided by the Diréctor of Education were the Dynamic Leaming Maps (LM) manual for administering the assessment and the PowerPoint created by the NHDOE for administering the assessment. The monitoring team interviewed staff at the High School regarding the curriculum being implemented, the foundation for curriculum, and how progress is measured. One teacher was asked about her curriculum and had fo go in to ‘the computer and find a curriculum labeled 2008. The curriculum stated that the teacher would use Life Skills Enatish 2003, Building Basic Enalish Skis, ‘Meetings & Messages, and the teacher could not produce copies of the textbooks through which the curriculum would be implemented. The teacher told the monitoring team that she individualizes the student's work. Other High School teachers were asked about curriculum and responded that the ‘curriculum was in the process of being developed and were not able to produce evidence of the curently approved curriculum from which they were instructing. The moritoring team interviewed one teacher at the Elementary School about curiculum and was provided a binder which included tabs for Language Arts, Math, Science, & Social Studies which comprised a list of skil outcomes for each grade level, and was not determined fo be a curriculum. One teacher provided ‘a. copy of DLM Leaming Standards for English and Math. However, he monitoring team did not see any evidence of implementation. Methods and Materials reviewed by the monitoring team included teacher-created materials.‘Tina Trudel, Chief Operating Offcar Lakeview Neurorehabiltation Center March 11, 2018 Page 27 of 32 The monitoring team did not see evidence of the implementation of an approved school-wide curriculum for grades 1-12. The monitoring team did not see evidence of the implementation of an approved altemative curriculum. Upon request from the monitoring team, as another way to verity that curriculum was being implemented, the teachers interviewed were unable to provide lesson plans. The monitoring team did not see evidence that the Teacher's Aides were familiar with the student's IEPs, nor had they been provided with a copy of the currently implemented IEP. Behavior interventions Ed 1114.07(b) Each private facility or other non-district program shall have a written statement of the Policies and procedures followed by the program in managing student behavior. This statement shall be provided to the sending LEA and the parent at the time each child with a disability becomes enrolled in the program, at the time of the annual review of the child's educational progress, and any time the facility or non-district program's policies and procedures for managing behavior are revised. Lakeview School did not provide evidence of written policies and procedures for managing student behavior nor did the Bureau observe any procedures. Action Required: Lakeview School is to develop written policies and procedures for managing student behavior. Lakeview School must train all school staff on the written policies and procedures and show evidence to the Bureau of who participated in the training as well as the content of the training. In addition, Lakeview School must show evidence that the written policies and procedures are provided to each sending LEA and each parent. The updated, board approved written policies and procedures; the training agenda and staff sign-in sheet; and evidence of the policies being provided to sending LEAs and parents must be provided to the Bureau. 1s of the date of | this letter INovember 14,2014), ‘ihn 2enonths of the ciate. of Evidence of Correction of Noncompliance Due: _| Evidence Received: December 16, 2014, January 14,2015 Evidence of correction of all instances of noncompliance was not provided within the established timeline. Review Status: As of January 26, 2015, Lakeview Schoo! has nat shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. }quired action: Submit updated, board approved policies and procedures for managing student behavior ° jence submitted by Lakeview f 16, 2014 te action: = Lakeview Schoo!’s Policies and Procedures, adopted by the Board of Directors effective December 12, 2014 were received on December 16, 2014. The statement regarding managing student behavior does not provide a description of how Lakeview School manages behavior. © Evidence submitted by Lakeview School on January 21,2015 to address the required ction: * Lakeview Schools’ Policies and Procedures that were submitted on January 21, 2015 did not have evidence of board approval. These policies and procedures were not reviewed for evidence of correction of noncompliance. © Evidence submitt view School Janvary 21 \d verified as board approv sary 27, 2015 to addi required action: = The statement regarding managing student behavior does not provide a description of how Lakeview School manages behavior. © Evidence reviewed during the February 26, 2015 on-site visit: * No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance.‘Tina Trude, Chief Operating Officer Lakeview Neurorehabiltaion Center March 11,2015 Page 28 of 32 ‘* Required action: Submit evidence to the Bureau that all school staff were trained on the written policies and procedures as well as the content of the training ° By mi view School on January 21, 2 ldress the required ction: = The training submitted is not based on the current NH Rules for the Education of Children with Disabilities, Amended as of May 15, 2014 or RSA 126:U. The rules referenced in the training refer to previous versions of the NH Rules. The training ‘also advises using Aversive Behavioral Interventions if authorized in writing by a physician and an IEP team. This statement refers fo a previous version of the NH Rule and is not in compliance with the current NH Rules. o Evidence reviewed during the February 26, 2015 on-site visit: = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. ‘+ Required action: Submit evidence that the written policies and procedures were provided to ‘each sending LEA and each parent © Evidence submitted is n. 15 to address the reaui action: No evidence submitted ° Evi ‘during the 26, 2015 on-site visit: = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards correction of noncompliance. ‘Suspected instances of Abuse Ed 111407(e) Each private facility or other non-district program shall have a writfen procedure based on state and federal law concerning the reporting of suspected instances of child abuse. Lakeview School did not provide evidence of written policies and procedures for reporting abuse ‘and neglect to either the Division for Children and Youth or the Bureau of Elderly and Adult Services. The statement on the BET form appears to be a barrier to complying with the state statute for mandated reporting since Lakeview Schoo! is required by this form to report to two individuals. ‘Action Required: Lakeview Schools to immediately develop written policies and procedures for reporting suspected abuse and neglect to Division for Children and Youth and Bureau of Elderly and ‘Adult Services. Lakeview School must immediately revise the BET form to comply with the state statute. The board approved written policies and procedures for reporting suspected abuse and the updated BET form must be provided fo the Bureau within 2 months of the date of this letter (November 14, 2014), Evidence of Correction of Noncompliance Due: _| Evidence Received: December 16, 2014. January 14, 2015 Evidence of correction of all instances of noncompliance was not provided within the established timetine. Review Stalus:__ As of January 26, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues fo be a finding of noncompliance, ‘As of March 11, 2015, Lakeview School has not shown evidence of coection of the noncompliance. This area continues to be a finding of noncompliance. * Required action: Submit updated, board approved pollcles and procedures for reporting suspected abuse and neglect to Division for Children and Youth and Bureau of Elderly and Adutt Services idence subr kevis ber 16, 2014 to address the requir "= Lakeview School's Policies and Procedures, adopted by the Board of Directors effective December 12, 2014 were received on December 16, 2014. These policies and procedures state that reporting must be done no later than the next working day to the Division for Children, Youth and Families Central intake.‘Tina Trudel, Chief Operating Oticor Lakeview Nourorehabiltation Center March 11, 2015 Page 29 of 32 Lakeview Schools' policies and procedures also make no mention of reporting instances of abuse to the Bureau of Elderly and Adult Services. * Also provided December 16, 2014 was a document that stated the procedure for mandated reporting protocols which contradicted the information given in the policies and procedures by stating that if you suspect/observe abuse neglect, or exploitation you must notify a supervisor immediately. ° Bi it Lakeview on January 21, 2015 ss the required action: Lakeview Schools’ Policies and Procedures that were submitted on January 21, 2015 did not have evidence of board approval. These policies and procedures were not reviewed for evidence of correction of noncompliance. © Evidence submitted by Lakevi nuary 21, 2015 and verified as board gpproved on January 27, 2015 to address the required action: = Lakeview Schoo''s Policies and Procedures state that reporting must be done no later thon the next working day to the Division for Children, Youth and Families Central intake. Lakeview Schools’ policies and procedures also make no mention of reporting instances of abuse to the Bureau of Elderly and Adult Services. © Evidence reviewed during the February 2 = No additional evidence was provided nor did the monitoring team observe evidence of progress being made towards corection of noncompliance. + Required action: Submit BET form that complies with the state statute. © Evidence submitted by Lakeview School on January 21, 2015 to address the required action: "No evidence submitted © Evidenc: fina the F 2 it: = No additional evidence was provided nor did the monitoring team observe ‘evidence of progress being made towards correction of noncompliance. Program Requirements: Certificalion and Ucensure, Ed 1114,05() All administrative, instructional, and related service staff shall hold appropriate certification or licensure for the position in which they function as required by the State of New Hampshire, and other licensing entities. The determination of credentials required shall be made by the department. &d 1114.10{a) All administrative, instructional, and related service staff shall hold appropriate certification for the position in which they function as required by the State of New Hampshire or other licensing entity evidence of such qualification shall be on record with the program. Lakeview School did not provide evidence that all administrative, instructional, and related service staff hold appropriate certification. There also was no evidence of what position individuals were hired for including the position of substitute teacher. ‘Action Required: Lakeview School must provide a compiete personnel roster of all adminisirative, instructional, and related service staff including consuitants and the certification they hold, the date ‘that the certification expires and the role that they are hired for. The complete personnel roster must be provided to the Bureau within one month of the date of this letter (November 14, 2014). Also include evidence of the contract of Andy Anderson's work for Lakeview School including whether or not school districts are aware of his work. Evidence of Correction of Noncompliance Due: _| Evidence Recelved: December 16, 2014, January December 14, 2014 21, 2015, February 26, 2015 subsequent on-site Visit. Evidence of correction of noncompliance was not provided within the established timeline.‘Tina Trudel, Chief Operating Officer Lakeview Neurorenablitaton Center March 11, 2015, Page 30f 32 Review Status: As of January 7, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘As of January 26, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘As of March 11, 2015, Lakeview Schoo! has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. «Required action: Submit complete personnel roster to the Bureau. ‘0 Evidence submitted by Lakeview School on December 16, 2014 to address the required ‘action; = Personnel rosters for school personnel and contracted services personnel were received on December 16, 2014. All rosters are dated October 29, 2014. Three staff appear both on the school personnel roster and on the contracted services roster. There are multiple staff mentioned in the training documents as working directly with students who do not appear on any of the personnel rosters. * Copies of certifications for school personnel and contracted services personnel were received on December 16, 2014. Some of the copies are unreadable. Not all cerfified staff on the personnel rosters have copies of their certifications provided. Evi submitted by Lakeview Sch 2 .ddress the required = Personnel rosters for school personnel and contracted services personne! were received on January 21, 2015. There are staff mentioned on the training documents submitted January 21, 2015 who do not appear on the personnel rosters. = Copies of certifications for school personnel and contracted services personnel were received on January 21, 2014. One cerfificate wos expired. The individual who is assigned the role of behavior specialist has a certificate from the ‘Academy of Certified Brain injury Specialists which expired on October 28, 2014. © Evidence revi juring the Fet 15 on: * Additional instances of this finding were identified on February 26, 2015. Required action: Submit a copy of Andy Anderson's contract ° ipmitted view School mi idress the r = Acopy of Andy Anderson's contract was received on December 16, 2014. The ‘copy not signed by Andy Anderson and is written as effective for one year starting March 11, 2011. ° Evi ited by Lakeview School on January 21,2015 to ac required action: = Acopy of Andy Anderson's signed contract was received on January 21, 2015. The legal name on the contract does not match the legal name listed on the background check provided with the contract, © Evidence reviewed during the February 26, 2015 on-site vist: = No additional evidence was provided.Lakeview Neurorehabiltation Center March 11, 2015 Page 31 of 32 ‘Qualifications and Requirements for instructional, Administrative, and Support Personne! Employee and Volunteer Background investigations Ed 1114.10(f) Each private provider of special education or other non-LEA program shall complete a background investigation and a criminal history records check on every selected applicant prior to ‘employment consistent with Ed 1114.11. Ed 1114.11 (a) Each private provider of special education or other non-LEA program, including any individual providing direct services to the student pursuant to Ed 1126.05, shall complete a background investigation, consistent with the provisions of RSA 189:13-a, prior to a final offer of employment. ‘Action Required: When Lakeview School provides a complete personnel roster of all administrative, instructional, and related service staff including consultants and the certification they hold, the date that the certification expires and the role that they are hired for; Lakeview School must also provide evidence that criminal history records checks were completed. Evidence of Correction of Noncompliance Due: _| Evidence Recelved: December 16, 2014, January December 14, 2014 21, 2015, February 26, 2015 subsequent on-site Visit. Evidence of correction of noncompliance was not provided within the established timeline, Review Status: As of January 7, 2015, Lakeview School has nat shown evidence of correction of the’ noncompliance. This area continues to be a finding of noncompliance. As of January 26, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area continues fo be a finding of noncompliance. ‘As of March 11, 2015, Lakeview School has not shown evidence of correction of the noncompliance. This area confinves to be a finding of noncompliance. * Required action: Pravide evidence of criminal Nery checks fr complete personnel rosters, ° nce submitte! + Copies of criminal history checks were received on December 16, 2014. Criminal history checks were not found for one of the personnel listed on the school personnel roster and for any of the personnel on the contracted services personnel roster. A criminal history check was included for a person not listed ‘on the personnel roster ° Evi itted by Lakevi H jary 21, 2015 to address the = Copies of criminal history checks were received on January 21, 2015. Criminal history checks were not found for those personnel listed on the training documents that were not included on the personnel rosters. * There was no evidence of a current personnel roster with all administrative, instructional, and related service staff including consultants and the certifications they hold, the date the certification expires, and the role that they are hired for. ‘Copies of the IEP and Evidence of Implementation Ed 1109.04(a) The LEA shall provide each teacher and service provider listed as having responsibilities, for implementing the IEP with a copy of the complete IEP for working and monitoring purposes. In ‘addition, the LEA shall provide a private school or non- LEA provider responsible for implementing the IEP with a copy of the IEP on or before the fist day of the placement. ‘Action Required: Lakeview School must ensure that each teacher and service provider listed as having responsibilities for implementing the IEP receives a copy of the complete IEP for working and monitoring purposes. Evidence of this corrective action must be provided to the NHDOE wit month of the date of this letter (November 14, 2014)‘Tina Trudal, Chief Operating Offcar Lakeview Neurorenabitation Center March 11,2015 Page 320132 Evidence of Correction of Noncompliance Due: | Evidence Received: February 26, 2015 December 14, 2014 subsequent on-site visit. Evidence of correction of noncompliance was not provided within the established timeline. Review Status: As of January 7, 2015, Lakeview Schoo! has not shown evidence of corection of the noncompliance. this area continues to be a finding of noncompliance. ‘As of January 26, 2015. Lakeview School has not shown evidence of correction of the noncompliance. This area continues to be a finding of noncompliance. ‘As of March 11, 2015, Lakeview School has nat shown evidence of correction of the. noncompiiance. This area continues to be a finding of noncompliance. «Required action: Provide evidence that each teacher and service provider listed as having responsibiliies for implementing the IEP receive a copy of the complete IEP. ° submitted, ew School on. 1 16, 2014 to add ited action: * No evidence received. In the table of contents received with the documents on December 16, 2014 Section 8 is listed as containing Copies of IEP and Evidence of Implementation. This section was not found in the documents provided. © Evidence submitied by Lakeview School on January 21, 2015 to address the required action: = Noevidence received © Evidence revi xing the Feb ite visit: ‘= The Director of Special Ed pulled out her training notebook for evidence that each teacher and service provider, having responsibilities for implementing the IEP, received a copy of the current IEP. There was nothing in that section of the notebook. When the monitoring team interviewed staff that each teacher and service provider received a copy of the current IEP. Staff referenced the classroom copies of the IEP’s though did not indicate that they had received their own copy. Staff were not able to provide evidence to the monitoring team that each had received their own copy of the IEPs. Ifyou have any questions regarding this matter, please feel free to contact me directly at 271-6693. Sipsgrely, 59 Thibedeau ‘Administrator, Bureau of Special Education State Director of Special Education cc: Christopher Slover, Chief Executive Officer NHDOE File