NH DHHS - Releases Report on Licensing Review of Lakeview NeuroRehabilitation Center

Concord, NH – The New Hampshire Department of Health and Human Services

(DHHS) released a report on a licensing complaint inspection review of

Lakeview NeuroRehabilitation Center. Lakeview NeuroRehabilitation Center is

an 88-bed residential facility located in Effingham, New Hampshire that

cares for individuals with physical, neurological, cognitive, and

behavioral impairments. The inspection was prompted by a complaint filed by

the New Hampshire Disabilities Rights Center in late September.

The licensing review of Lakeview focused on its current operation and

whether the facility was in compliance with the regulatory requirements set

forth in NH RSA 151 and He-P 807.

In its review, the team focused on three primary questions:

1. Does Lakeview comply or not comply with the requirements set forth in

NH RSA 151 and He-P 807?

2. Do the current practices, policies and resources at Lakeview provide

appropriate assessment, treatment planning, case management,

discharge planning and related services for residents consistent with

regulations and best practices?

3. Does Lakeview have in place appropriate procedures and policies to

effectively ensure the safety of residents, staff and visitors?

The review found that chronic and acute staffing deficits; not maintaining

proper levels of supervision at all times; admitting residents with a

higher level of acuity than the facility can effectively handle;

deficiencies in training, communication, crisis management and program

oversight; and lack of a robust quality improvement function have

contributed at times to problematic incidents and “bad outcomes” for

program residents. The report states that Lakeview is required to submit an

acceptable Plan of Correction (POC) to address and ameliorate the issues

identified in the report and to come into compliance with statutory and

regulatory requirements.

Lakeview must submit a Plan of Correction to the Department by December

31st (21 days from the date Lakeview was provided the report He-P 807.12).

The POC must address:

o How the licensee intends to correct each deficiency;

o What measures will be put in place, or what system changes will

be made to ensure that the deficiency does not recur; and

o The date by which each deficiency shall be corrected.

Once the POC is accepted, the Department will post it online along with the

inspection report.

According to Deputy Commissioner Marilee Nihan, “This report raises serious

concerns about Lakeview’s ability to provide quality care in a safe and

effective way to this vulnerable population. While I do appreciate the

difficulties and complexities in providing safe care and treatment to those

with severe brain injuries, individuals must be provided with safe, quality

care. The findings in this report illustrate that Lakeview needs to greatly

improve and maintain its staffing, training, and quality systems.”

The licensing report is now available on the facilities licensing page at


and by typing in Lakeview under Facility Name.