DHS OIG FY 2007 Annual Report

Helping Families. Supporting Communities. Empowering Individuals.

November 2007


To Governor Rod R. Blagojevich and Members of the Illinois General Assembly:


I am pleased to submit to you this Fiscal Year (FY) 2007 Annual Report of the Office of the Inspector General (OIG) in the Illinois Department of Human Services (DHS), entitled: Abuse and Neglect of Adults with Disabilities. The report fulfills the requirements in OIG's enabling statute (210 ILCS 30/6.2, now 20 ILCS 1705/1-17) and the Adults with Disabilities Domestic Abuse Intervention Act (20 ILCS 2435).

This annual report highlights what OIG has accomplished during FY 2007 in seeking to ensure thorough reporting and investigating of alleged abuse and neglect of adults who have disabilities. The report also highlights what OIG has done to eliminate incidents of abuse and neglect and to prevent recurrence when they happen.

This annual report follows OIG's strategic planning process for FY 2007. OIG's mission drove the development of four priority strategic objectives for OIG performance for the fiscal year. Then, within each strategic objective, OIG established specific initiatives, with at least one benchmark for measuring OIG performance during the year. The report presents OIG performance against these benchmarks in three ways: a measurement compared to the benchmark; a percent of the benchmark met; and the trend over the past three years, where applicable. The purpose is to show OIG's FY 2007 accomplishments in a comprehensive, measurable, and concise manner.

OIG is fully committed to preventing and responding fully to abuse and neglect of individuals who have disabilities, and the numbers tell only part of the story. OIG's activities and services during the fiscal year are also summarized under each benchmark. I trust that you will find this unique approach to be informative and helpful in understanding OIG's commitment and efforts.


Sincerely,


William M. Davis

Inspector General


  1. FY 2007 OIG Highlights
  2. OIG STRATEGIC MAP, FY 2007
    1. OIG Mission
  3. Priority I - Fulfilling statutory mandates related to abuse/neglect
    1. Summary for Priority I: Fulfilling statutory mandates related to abuse/neglect
    2. Initiative I.A: Conduct annual unannounced site visits to facilities.
    3. Initiative I.B: Provide training to OIG, facility and agency staff.
    4. Initiative C: Manage reports of allegations and deaths.
    5. Initiative D: Investigate allegations and deaths.
    6. Initiative E: Monitor implementation of Written Response actions.
    7. Initiative F: Refer names to the IDPH Health Care Worker Registry.
    8. Initiative G: Include facility staffing ratios in the Annual Report.
  4. Priority II - Streamlining processes and procedures
    1. Summary for Priority II: Streamlining processes and procedures
    2. Initiative A: Ensure all abuse/neglect allegations are investigated.
    3. Initiative B: Address OIG interview timeliness and documentation.
    4. Initiative C: Facilitate access to OIG database case management.
    5. Initiative D: Reduce days required to complete OIG investigations.
    6. Initiative E: Streamline Registry appeals hearing process.
    7. Initiative F: Draft legislative revisions to update statute.
  5. Priority III - Supporting quality programs
    1. Summary for Priority III: Supporting quality programs
    2. Initiative A: Ensure timely initial reporting by community agencies and facilities.
    3. Initiative B: Authorize community agencies to investigate, when appropriate.
  6. Priority IV - Partnering with others
    1. Summary for Priority IV: Partnering with others
    2. Initiative A: Collaborate with stakeholders to reduce occurrence of abuse/neglect.
    3. Initiative B: Utilize external resources for improved training.
    4. Initiative C: Ensure first response training of selected staff.
    5. Initiative D: Expand partnerships with law enforcement regarding OIG's mission.

FY 2007 OIG Highlights

During State Fiscal Year (FY) 2007, the Office of the Inspector General (OIG) in the Illinois Department of Human Services (DHS) accomplished the following:

  • Managed 2,562 new allegations of abuse/neglect - 10% more than during FY 2006 and 17% more than during FY 2005 - and of these 2,562 allegations:
    • 866 were at DHS facilities, down 7.5% since FY 2005,
    • 1,044 were at community agencies, up 27% since FY 2005, and
    • 652 were in domestic settings, up 23% since FY 2005;
  • Completed 2,557 total investigations in FY 2007:
    • 1,938 Rule 50 investigations in an average of 46 days/case, compared to 1,788 Rule 50 investigations in FY 2006 in an average of 53 days/case -
      • that is, 8% more cases done 13% faster; and
    • 619 Rule 51 investigations in an average of 37 days/case, in comparison to 608 Rule 51 investigations in FY 2006 in an average of 42 days/case -
      • that is, 2% more cases done 12% faster.
  • Closed 2,517 investigations into alleged abuse/neglect - 14% more than FY 2006 and 15% more than FY 2005 - and of these allegations (and four deaths):
    • 353 were substantiated, up 20% since FY 2005, - 227 as abuse, 119 as neglect, and seven as domestic exploitation, and
    • 435 were not substantiated, but OIG cited administrative issues, up 108% since FY 2005.
  • Handled new reports of 137 deaths in DHS facilities or community agency programs, and completed a review on 111 of these deaths and another 26 reported in the previous fiscal year, substantiating neglect in one death;
  • Conducted an unannounced site visit to each of the eighteen DHS facilities, making over 100 recommendations aimed at preventing abuse and neglect;
  • Updated OIG's Handbook for Reporting Abuse and Neglect of Adults with Disabilities and began distributing it during all OIG trainings;
  • Worked with the DHS program divisions to require biennial training of all community agency staff and volunteers on reporting abuse and neglect;
  • Reviewed and identified missing elements in reporting policies at over 90% of the 372 community agencies within OIG jurisdiction through June 30, 2007;
  • Approved 162 community agencies to investigate certain types of cases at OIG's direction and with OIG's guidance;
  • Began recording in its database all complaints that do not meet the definitions of abuse or neglect in Rule 50;
  • Replaced 41 outdated computers and created a stand-alone Case Actions Program, allowing investigators to data-enter investigative case actions into the database even when not connected to the network; and
  • Conducted a customer satisfaction survey of the facilities and agencies, receiving high marks for OIG's professionalism and identifying a few specific areas for continued improvement.

OIG STRATEGIC MAP, FY 2007

OIG Mission

The Office of the Inspector General assists agencies and facilities in prevention efforts by investigating reports of abuse, neglect, and deaths in a timely manner to foster humane, competent, respectful, and caring treatment of persons with mental illness or developmental disabilities.

OIG Strategic Objectives for FY 2007

Priority I: Fulfilling statutory mandates related to abuse/neglect

Priority II: Streamlining processes and procedures

Priority III: Supporting quality programs
 

Priority IV: Partnering with others
 
 

A. Conduct annual unannounced site visits to facilities. A. Ensure all abuse/neglect allegations are investigated. A. Ensure timely initial reporting by community agencies and facilities. A. Collaborate with stakeholders to reduce occurrence of abuse/neglect.
B. Provide training to OIG, facility, and agency staff. B. Address documentation of OIG interviews. B. Authorize com-munity agencies to investigate, when appropriate. B. Utilize external resources for improved training.
C. Receive reports of allegations and deaths. C. Facilitate access to OIG database, case management. C. Ensure first response training of selected facility and community agency staff.
D. Investigate allegations and deaths. D. Reduce days required to complete OIG investigations. D. Expand partnerships with law enforcement regarding OIG's mission.
E. Monitor implemen-tation of written response actions. E. Streamline Registry appeals hearing process.
F. Refer names to the Health Care Worker Registry. F. Draft legislative revisions to update statute.
G. Include facility staffing ratios in the Annual Report.


Priority I - Fulfilling statutory mandates related to abuse/neglect

Table 1 - Detailed Performance Scorecard for Priority I Strategic Objective:
Fulfilling statutory mandates related to abuse/neglect.
Initiative Benchmark Measure Performance Measurement Performance Result Performance Trend (and 3-year trend*)
A. Conduct annual unannounced site visits to facilities.

1) Do all 18 site visits by March 31.

2) Finish the report on each site visit within 60 days.

1) The final site visit was March 29-30.

2) All reports were done in 60 days.

1) 100%


2) 100%

1) No change


2) Improvement

B. Provide training to OIG, facility, and agency staff.

1) Ensure all OIG staff meet continuing education goal.

2) Conduct 80 OIG trainings of facility and agency staff.

1) All staff met the CE goals.


2) Conducted 85 external OIG trainings.

1) 100%


2) 106%

1) No change


2) Improvement

C. Receive reports of allegations and deaths.

1) Manage 2,339 new allegations and 143 new reports of death (FY 2006 totals).

2) Refer 10% of all ineligible domestic complaints (FY 2006 percentage).

1) Managed 2,562 new allegations and 137 new reports of death.


2) Referred 13 (9%) of 144 ineligible domestic complaints

1) 109%


2) 90%

1) Improvement


2) No charge

D. Investigate allegations and deaths.

1) Cite issues in clinical reviews of death cases.

2) Handle requests for reconsideration appropriately.

3) Close a total of 2,353 cases. (FY 2006 total).

4) Refer 100% of the substantiated domestic cases for service plans. (FY 2006 pecentage).

1) Issues cited in five deaths.


2) 93 requests,

7 revised findings.


3) Closed a total of 2,656 cases.


4) Referred all 117 (100%) of victims in substantiated domestic cases.

1) 100%


2) 100%


3) 129%


4) 100%

1) No change


2) No change


3) Improvement


4) No change

E. Monitor imple-mentation of written response actions.

1) 50% of approved Written Responses received within 30 days.

2) In 20% sample reviewed, 100% in compliance.

1) 40% of these were received within 30 days.


2) 20% reviewed and 100% were in compliance.

1) 80%


2) 100%

1) Decline


2) No change

F. Refer names to the Health Care Worker Registry. 1) Refer 100% of appropriate referrals to the Registry. 1) Referred all 66 names to the Registry 1) 100% 1) No change
G. Include direct care staffing ratios. 1) Include direct care to patient ratios for all DHS facilities. 1) Included facility direct care ratios in this Annual Report. 1) 100% 1) No change

* Three year trend, where applicable, covers FY 2005 through FY 2007

Summary for Priority I: Fulfilling statutory mandates related to abuse/neglect

This section displays results for this FY 2007 strategic objective and related initiatives by specific benchmark measure. It summarizes OIG performance during the fiscal year and the narrative that follows provides relevant detail about each benchmark.

FY 2007 Summary for Priority I Strategic Objectives
Related Initiatives Total Benchmarks Average Results Targets Met
7 14 101% 85.7%

Related initiatives for this strategic objective:

  1. Conduct annual unannounced site visits to facilities
  2. Provide training to OIG, facility and agency staff
  3. Receive reports of allegations and deaths 
  4. Investigate allegations and deaths
  5. Monitor implementation of Written Response actions
  6. Refer names to the IDPH Health Care Worker Registry
  7. Include facility staffing ratios in the Annual Report

Initiative I.A: Conduct annual unannounced site visits to facilities.


I.A.1

Benchmark I.A.1 - All 18 site visits done by March 31, 2007.

FY 2007 Result - The final FY 2007 site visit was March 29-30, 2007.


The statute creating OIG (210 ILCS 30/6, but 20 ILCS 1705/1-17 since August 28, 2007) mandates annual unannounced site visits to DHS's developmental centers and psychiatric hospitals. Each year, OIG develops a unique Site Visit Plan, with a goal to cover a wide range of activities, initiatives, and potential problem areas related to preventing abuse and neglect.

Dates

In FY 2007, the site visits were conducted by two teams, each consisting of two OIG staff, one of whom is a registered nurse. OIG completed these eighteen unannounced site visits as follows:

  • Alton MHCOctober 17-18, 2006
  • Chester MHCAugust 30-31, 2006
  • Chicago-Read MHCAugust 30-31, 2006
  • Choate DCMarch 26-28, 2007
  • Choate MHCMarch 28-30, 2007
  • Elgin MHCMarch 28 and 29, 2007
  • Fox DCJuly 27-28, 2006
  • Howe DCDecember 27-28, 2006 and January 2-3, 2007
  • Jacksonville DCMarch 1-2, 2007
  • Kiley DCOctober 25-26, 2006
  • Ludeman DCJanuary 30-31, 2007
  • Mabley DC, July 25-26, 2006
  • Madden MHCNovember 28-29, 2006
  • McFarland MHC, December 18-20, 2006
  • Murray DCJanuary 9-10, 2007
  • Shapiro DCSeptember 14-15, 2006
  • Singer MHCSeptember 27-28, 2006
  • Tinley Park MHCFebruary 26-27, 2007
Findings
Site Visit Issue 1: FY 2006 Recommendations

OIG followed up on all 58 recommendations from FY 2006 site visits to ensure action was taken. Facilities had implemented actions that fully addressed only 44 of the recommendations. The most common of the remaining fourteen recommendations (nine facilities) were related to: conducting or following up on consumer satisfaction surveys (three), ensuring adequate training of staff on abuse/neglect reporting (three), and documenting Human Rights Committee meeting minutes (two).

Site Visit Issue 2: Progress Notes

Progress notes document an individual's condition, care, and treatment, record important events, and communicate his/her status and needs to other staff; so they are critical to preventing abuse/neglect. Problems OIG found were missing progress notes or problems in the areas of error correction, blank spaces, and missing times of notes. In all, OIG made ten recommendations (eight facilities), asking facilities to remind staff of the correct documentation procedures.

Site Visit Issue 3: Clinical Assessments

Nursing assessments and external consultations raise care/treatment issues and provide recommendations, and a failure to address these may lead to neglect or abuse. After reviewing a sample of these at each facility, OIG made a total of eleven recommendations (seven facilities). Five recommendations involved revising a current policy to be more specific or to reflect current practice. Three recommendations were to improve monitoring by keeping or improving tracking logs. Two recommendations were to re-train staff in requirements, and the final recommendation was to ensure that medication education is included in the habilitation plan.

Site Visit Issue 4: Continuity of Care

Lack of continuity of care across programs while an inpatient - when developmental center residents go to day programs and when psychiatric hospital residents transfer to another unit or facility - may lead to neglect or abuse. OIG reviewed the facility's policies and made eight recommendations (seven facilities). The common problem was the absence of specific elements (e.g., medication, diet or program changes), and OIG recommended that the facility add these.

Site Visit Issue 5: Emergency Response

Events requiring facility staff to respond on an emergency basis increase the possibility for abuse or neglect by staff, so OIG reviewed facility policy/procedures, training, and records of drills. OIG made 33 recommendations (sixteen facilities). The most common recommendation was to create or update the medical emergency drill policy or recording form. Related recommendations were to ensure that the drills were conducted on all shifts as already required or to maintain comprehensive documentation of corrective actions. The second most common recommendation was to update the CPR policy and ensure training.

Site Visit Issue 6: Reportable Incident Response

OIG reviewed the facility's internal reporting policy and training curriculum for proper reporting and preserving evidence, as well as training of facility employees who conduct investigative activity at OIG's direction. OIG made 25 recommendations (seventeen facilities), sixteen of which were that all staff who conduct OIG interviews should remain current with OIG-conducted Rule 50 and Basic Investigative Skills training.

Site Visit Issue 7: Non-Reportable Incident Response

OIG reviewed the facility's handling of non-reportable complaints - whether called in to the OIG Hotline or documented on Human Rights Complaint forms - to ensure underlying problems were addressed before they worsen and become abuse or neglect. OIG made eleven recommendations (nine facilities). OIG recommended that three facilities ensure all staff know that, when they call in a complaint that OIG determines to be non-reportable, the staff then know to report it to the facility's OIG Liaison, so follow-up can be done. OIG recommended to three other facilities that they fully document the follow-up done on each non-reportable complaint. OIG recommended to one facility that they create a facility policy that implements all requirements of the DHS policy.

Site Visit Issue 8: Patient Safety Initiative

OIG reviewed documentation of physical plant improvements the facility reported taking since the date of the last site visit. OIG made two recommendations (two facilities). OIG recommended one facility consider conducting a full patient safety risk assessment in all areas. OIG recommended that the other facility revise its policy to require written documentation of visitor entry and screening.


Overall, OIG made 114 recommendations during the FY 2007 unannounced facility site visits. While some were minor policy clarifications or reminders to staff, OIG will be following up on all recommendations during the FY 2008 site visits.


I.A.2

Benchmark I.A.2 - All FY 2007 site visit reports done in 60 days.

FY 2007 Result - All reports were completed within 60 days.


Each OIG site visit is done by two staff: one of OIG's two registered nurses (RNs), and one of OIG's two compliance reviewers. During FY 2005 and FY 2006, both of the administrative site visitors resigned, and only one of the positions has been filled. Still, OIG was able to complete eight (44%) of the eighteen FY 2005 site visits and fourteen (78%) of the FY 2006 site visits within 60 days.

The vacant positions were filled in FY 2006 and OIG streamlined the site visit report format. As a result, all eighteen (100%) of the FY 2007 site visit reports were completed within 60 working days. OIG also ensured that findings are discussed with facility administrators at an exit conference at the end of the actual site visit, so corrective actions can be taken immediately, even if there is a delay in the written report.


Initiative I.B: Provide training to OIG, facility and agency staff.


I.B.1

Benchmark I.B.1 - All OIG staff meet continuing education goals.

FY 2007 Result - All met goals by June 30, 2007.


OIG is required by statute to establish a comprehensive program to ensure that every current or new investigator receives ongoing training in investigative skills and communication skills, especially with individuals residing in DHS facilities. OIG's Directive on training (ADM 01-002) identifies specific training requirements for new investigators and mandates that every current investigator receive five courses each year, including at least one in each of the following areas: investigative skills, computer skills, and personal/professional development.

OIG's 37 investigative staff completed a total of 396 courses during FY 2007, an average of more than ten courses per person. That is, by June 30, 2007, these 37 OIG staff members completed an average of five and a half investigative skills courses, one and a half computer skills courses, and nearly four personal or professional development courses.


I.B.2

Benchmark I.B.2 - Conduct 80 OIG trainings of agency and facility staff.

FY 2007 Result - OIG conducted 85 trainings during FY 2007.


OIG is also committed to providing training as a means to prevent abuse/neglect and to adequately report, effectively investigate, and thoroughly respond to allegations. In FY 2007, OIG again offered four courses for staff of programs operated, licensed, certified, or funded by DHS to provide mental health or developmental disability services. The first is a four hour training regarding Rule 50, the administrative regulation that governs the reporting and investigating of abuse and neglect. In FY 2007, OIG conducted 35 Rule 50 classes with a total of 790 attendees.

The second course is a First Responder class for any staff who may need to respond to a scene of possible abuse or neglect. This class concentrates on ensuring the health and safety of all those involved and on securing the scene and preserving evidence. In FY 2007, OIG conducted 13 First Responder classes with a total of 164 attendees.

The third course, Basic Investigative Skills, is a two-day class that concentrates on all aspects of conducting an administrative investigation. This course is required for anyone who an agency or facility wishes to designate, with OIG's authorization, to conduct investigations. In FY 2007, OIG conducted 24 Basic Investigative Skills classes with a total of 296 attendees.

The final course is an Investigative Skills Refresher, which is a one-day class for those who have already completed the Basic Investigative Skills course. It includes a refresher of Rule 50 and investigative skills. In FY 2007, OIG conducted 13 Investigative Skills Refresher classes with a total of 106 attendees.

In all, during FY 2007, OIG conducted 85 classes with a total of 1,356 attendees.


Initiative C: Manage reports of allegations and deaths.


I.C.1

Benchmark I.C.1 - Receive 2,339 allegations of abuse/neglect and 143 death reports.

FY 2007 Result - OIG received 2,562 allegations and 137 deaths in FY 2007.


During FY 2007, OIG received a total of 2,562 allegations of abuse or neglect. A breakdown of the counts by location and type is shown in the table below.

Table 2 - Allegations Received in FY 2007 by Type and Setting
Location Abuse Allegations Neglect Allegations Total Allegations
Rule 50 - DHS facilities 762 104 866
Rule 50 - Community agencies 772 272 1,044
Rule 51 - Domestic settings 268 325  652*
Totals 1,802 701  2,562*

* Includes 59 allegations of domestic exploitation

Four-year trend

The 2,562 allegations OIG received during FY 2007 is a 9.5% increase over the 2,339 received during FY 2006. However, allegations of abuse rose 5% (from 1,709 to 1,802), while allegations of neglect jumped 20% (584 to 701). Abuse allegations have risen slower than neglect allegations for several years.

The 2,339 total allegations OIG received in FY 2006 was 6.8% higher than the 2,191 received in FY 2005, which was 34.1% more than the 1,634 received FY 2004. Thus, over the past four years, OIG has experienced a 56.8% increase in allegations, yet with no increase in budgeted headcount.

Facilities

As the number of facility residents has decreased, the number of allegations also has declined. So, contrary to the overall trend, allegations received about DHS-operated facilities during FY 2007 dropped 6% over FY 2006 and was 7.5% lower than FY 2005. However, a large jump from FY 2004 to FY 2005 means that the number of allegations OIG received about facilities in FY 2007 was still 32% higher than four years ago.

As in years past, abuse allegations still account for the lion's share of all allegations; in FY 2007, 88% of allegations about facilities alleged abuse. Yet, the recent drop in allegations about facilities has been entirely in allegations of abuse. Slightly more allegations of neglect were received during FY 2007 than in either of the two preceding fiscal years. In FY 2007, OIG received about the facilities 11% fewer abuse allegations than in FY 2005 but 24% more neglect allegations.

Agencies

While overall allegations at the DHS-operated facilities decreased over the past three years, the 1,044 allegations OIG received about community agencies in FY 2007 was a 17% increase over the 893 received in FY 2006 and a 27% rise over the 723 received in FY 2005. This continued increase in allegations about agencies coupled with the recent drop in allegations about facilities means that, in FY 2007 for the first time, OIG received more allegations about agencies than about the facilities. This is due in part to the larger number of individuals receiving services in the community.

Like the facilities, allegations at agencies are more often abuse allegations. However, also like the facilities, neglect allegations have increased more. In FY 2007, OIG received about the agencies 40% more abuse allegations than in FY 2005 and 58% more neglect allegations.

Domestic

Allegations from domestic settings took another jump in FY2007 after a slight drop in FY 2006. The 652 allegations OIG received about domestic settings during FY 2007 was 24% higher than the 525 received in FY 2006, 23% higher than the 531 received in FY 2005, and 44% higher than the 452 received in FY 2004. Domestic abuse, neglect, and exploitation allegations all were higher in FY 2007 than ever before.

The relative percentage of reported allegations by type remained relatively similar to prior years, with 41% abuse, 50% neglect, and 9% exploitation. OIG has received more allegations of domestic neglect than domestic abuse each year for the past four years.

Allegations and Deaths Received

The tables that follow show more detail about the locations and types of allegations OIG received during FY 2007. The mental health service table separates a facility's "forensic" units - residential units for those committed by court order or who have aggressive behaviors - from the non-forensic ("civil") residential units. Chester MHC has only forensic units. McFarland MHC has a forensic unit, but no allegations were reported about that unit in FY 2007.

For community agencies, residential programs are distinguished from non-residential programs such as day treatment programs. Residential programs typically provide services for more hours each day than do non-residential programs, but the intensity of the interaction with staff varies with the actual services provided.

Table 3 - Rule 50 Allegations and Deaths Received in FY 2007, Mental Health Services Only
Facility or Agency Program Physical abuse allegation Sexual abuse allegation Mental abuse allegation Neglect allegation Allegation totals Death
Alton (civil) 15 5 5 3 28 0
Alton (forensic) 27 1 8 3 39 0
Chester 100 5 26 5 136 1
Chicago-Read 14 2 7 4 27 2
Choate (1) 21 1 15 3 40 1
Elgin (civil) 7 3 1 3 14 0
Elgin (forensic) 8 21 10 15 54 2
Madden 8 3 10 6 27 0
McFarland 10 0 6 2 18 2
Singer 14 3 5 3 25 2
Tinley Park 2 0 4 4 10 1
Facility subtotals 226 44 97 51 418 11
Residential 15 10 11 14 50 17
NonResidential 8 14 9 6 37 1
Agency subtotals 23 24 20 20 87 18
Rule 50 -
MH Totals
249 68 117 71 505 29

(1) Mental health units only.

Table 4 - Rule 50 Allegations and Deaths Received in FY 2007, Developmental Disability Services Only
Facility or Agency Program Physical abuse allegation Sexual abuse allegation Mental abuse allegation Neglect allegation Allegation Totals Death
Choate (1) 72 4 18 8 102 1
Fox 1 0 0 3 4 3
Howe 55 0 26 18 99 4
Jacksonville 81 2 13 7 103 5
Kiley 34 1 4 6 45 2
Ludeman 22 2 2 4 31 2
Mabley 10 1 1 2 14 1
Murray 12 0 3 2 17 3
Shapiro 28 0 2 3 33 8
Facility subtotals 315 11 69 53 448 29
Residential 317 27 123 188 655 73
NonResidential 153 23 62 64 302 6
Agency subtotals 470 50 185 252 957 79
Rule 50 -
DD Totals
785 61 254 305 1405 108
(1) Developmental disability units only; includes four allegations from the forensic unit
Table 5 - Rule 51 (Domestic Settings) Allegations Received in FY 2007
Diability Type Physical abuse allegation Sexual abuse allegation Mental abuse allegation Neglect allegation Financial exploitation allegation Allegation Totals (2)
DD 163 16 17 155 16 367
PD 39 2 6 126 18 191
MH 21 3 1 44 25 64
Rule 51 Totals 223 21 24 325 59 652

(2) Excludes complaints that were not reportable per the administrative rule.


OIG continues to look at the source of calls alleging domestic abuse, neglect, or exploitation. In FY 2007, the percentage reported by each source has changed slightly over previous years. The largest source was again community agencies, which accounted for 27% of all allegations, compared to 24% in FY 2006. In FY 2007, family members and friends were again a main source of domestic allegations, accounting for 20% of these allegations, compared to 18% in FY 2006. Hospitals accounted for 16%, compared to 17% in FY 2006.


I.C.2

Benchmark I.C.2 - Refer 10% of ineligible domestic complaints.

FY 2007 Result - OIG referred 13 of 144 ineligible complaints.


The state law governing OIG's program is the "Abuse of Adults with Disabilities Intervention Act" (20 ILCS 2435/1). This law contains specific eligibility criteria and definitions; for example, that the person needs to be between 18 and 59 years old, needs to be currently living in a domestic setting, and needs to be unable to seek and obtain help due to the disability.

OIG frequently receives complaints that, upon preliminary investigation, are found to be ineligible for the program. Although OIG does not do further investigation, OIG attempts to ensure that the alleged victim is receiving appropriate services when needed by making referrals to other entities.

In FY 2007, a total of 144 complaints were determined to be ineligible for the program: 83 of them by Intake investigators, and 61 by the investigative bureau. These 144 alleged victims were ineligible because:

  • 74 had no disability or were still able to seek and obtain help;
  • 23 had problems that had been resolved by the time OIG became involved;
  • 13 died (all of natural causes) prior to the completion of the OIG assessment;
  • 11 had problems not meeting the statutory definition of abuse, neglect, or exploitation;
  • 7 were either over 59 or under 18;
  • 7 were not in a domestic setting; and
  • 9 had other issues outside OIG jurisdiction (e.g., criminal or service complaints).

Thirteen of the ineligible complaints received in FY 2007 had ongoing issues that were not within OIG's jurisdiction. Eight were referred (or had been referred) to a local law enforcement agency, three went to the DHS Division of Rehabilitation Services, and one each to the Department on Aging and the Department of Children and Family Services.

Of note, OIG also makes referrals to other entities while investigating eligible cases as well, to provide services, ensure protection, or address issues beyond OIG's jurisdiction. In the eligible domestic cases investigated during FY 2007, OIG made a total of 260 referrals to other entities.


Initiative D: Investigate allegations and deaths.


I.D.1

Benchmark I.D.1 - Cite issues in clinical reviews.

FY 2007 Result - OIG cited issues in five deaths during FY 2007.


During FY 2007, OIG completed reviews or investigations into 139 deaths that had occurred in or shortly after discharge from programs under OIG jurisdiction. Of these 139 deaths, 42 individuals had been receiving services in DHS facilities and 97 in community agency programs. Neglect was substantiated in two of these deaths. In three other death cases, OIG did not substantiated abuse or neglect by staff but did cite administrative issues that the facility or agency needed to address.

Reported deaths
Facilities

Of the 42 deaths that had occurred in a DHS facility or within 14 days of discharge or transfer from a DHS facility, eleven individuals had been receiving services in a DHS psychiatric hospital and 31 had been receiving services in a DHS developmental center.

Of the eleven deaths reported by a DHS psychiatric hospital, two were determined to be suicides: one from a gunshot wound, and the other from being hit by a train. Neglect was not found in either case. Two of the remaining nine deaths were from a bowel obstruction. In one of these cases, the pathologist could not determine the manner of death due to unknown factors in the individual's history. The remainder of these deaths were from natural causes after discharge or transfer to a hospital. The average age of the eleven individuals was 41 years old.

Of the 31 deaths reported by a developmental center, seven were cardiac related, while four were from pneumonia and three from cancer. The average age of the 31 individuals was 54 years old. An autopsy was done on 18 of the cases to assist in determining the cause of death. In one case, the coroner's physician determined that the death was from choking but was accidental; no neglect was found in OIG's investigation either. Neglect was substantiated in none of the 42 deaths of DHS facility patients.

Agencies

Of the eighteen deaths of individuals receiving mental health services in the community, the most common manner of death was from natural causes: four were cardiac related, three were from respiratory conditions, and three were from cancer. Of the remaining eight deaths, three were drug or alcohol related, two were from post-operative complications, and one was the accidental drowning in a bathtub of an individual with a seizure disorder. The average age of the nineteen individuals was 48 years old.

Of the 79 deaths of individuals receiving developmental disability services in the community, the average age was 57 years old, and most of these were from natural causes. Twenty-two of the deaths were cardiac-related (including five from heart attacks), eleven were from pneumonia, and ten from cancer. One of the eleven from pneumonia resulted in a finding of neglect: the agency failed to provide prompt medical treatment and, by the time his mother picked him up for a home visit and instead took him to the hospital for treatment, his condition was too advanced. (Note: This case was completed in FY 2007, but was not closed until FY 2008).

One other death of an individual receiving developmental disability services in the community was also substantiated as neglect. A 19-year-old man died as a result of injuries received when he caught his head in a hydraulic baler at work. The investigation revealed that the agency staff had left him unsupervised. He was then able to obtain the key to use this dangerous piece of equipment, which he was not trained to use. As a result of this incident, the policy was changed and the warehouse assistant's job description was revised to formally assign the responsibility for direct supervision of all clients at the dock.

Recommendations

Even where neglect is not substantiated, OIG makes recommendations when appropriate to reduce the possibility of future incidents. The following are examples of recommendations OIG made to DHS facilities during FY 2007 in two deaths and in other investigations involving clinical issues.

  • Complete a bowel elimination assessment on all individuals - including the medical history, surgeries, medications, bowel history, and elimination pattern - and ensure the assessment is reviewed by the individual's physician for further recommendation.
  • Reinforce the facility's medical emergency policy, which states that 911 and CPR are to be initiated as trained in life-threatening situations first and then notify the unit nurse.
  • Conduct refresher training for nurses on critical thinking skills, medical observation, and notification of the physician of illness, injury, and changes in medical condition.
  • Improve progress note documentation.
  • Develop a formal risk assessment for use during discharge determination and planning.

The following are examples of recommendations OIG made to community agency programs during FY 2007 in three deaths and in other investigations involving clinical issues.

  • Improve CPR training, as the staff have continued to determine not to begin CPR.
  • Obtain functional evaluations of specific individuals to determine appropriate placement.
  • Change procedures in place to prevent injuries and infection.
  • Use medical alert identification for individuals with bleeding / medical disorders.
  • Re-train direct care staff in the recognition of illness and care of skin breakdown.

In addition, after several incidents regarding medication administration in DD community agency programs, OIG referred medication issues to the DHS Division of Developmental Disabilities' Bureau of Quality Assessment and System Improvement for training and follow-up.


I.D.2

Benchmark I.D.2 - Handle requests for reconsideration.

FY 2007 Result - OIG received 93 requests, changing the finding in seven cases.


When OIG first completes an investigation and notifies the person of the substantiations, he/she may file a "reconsideration" request with OIG in 15 working days of the date on the completion letter. Reconsiderations require that the person identify information that was not considered during the OIG investigation and that could change the outcome. If the finding is changed, OIG will not refer the person's name to the Registry.

A reconsideration had been requested on 93 of the cases OIG closed during FY 2007. Of the 93 cases, 63 had initially been substantiated, 16 not substantiated but with issues, 13 unfounded, and one unsubstantiated. Of the 93 reconsideration requests, OIG denied 74 requests and granted 19. OIG ultimately changed the finding in seven of these 19 cases: six cases were changed from substantiated to unsubstantiated, and one case was changed from unfounded to substantiated.


I.D.3

Benchmark I.D.3 - Close a total of 2,353 cases.

FY 2007 Result - OIG closed 2,656 cases during FY 2007.


During FY 2007, OIG closed a total of 2,656 cases:

  • 983 cases at DHS facilities;
  • 1,102 cases at community agency programs; and
  • 571 cases in domestic settings.

This continues an upward trend in the case closures from 2,091 in FY 2004 to 2,293 in FY 2005 and to 2,353 in FY 2006. That is, OIG closed 13% more cases this year than last and 27% more than three years ago.

Of the 2,656 cases closed in FY 2007, there were 2,517 allegations of abuse, neglect, or exploitation and 139 were deaths. Compared to FY 2006, these totals show a 14% rise in the number of closed allegations and a 2.8% drop in the number of closed death cases.

Broken out by service setting, during FY 2007, OIG closed:

  • 1,532 cases in DD settings - 1,423 allegations and 109 deaths;
  • 553 cases in MH settings - 523 allegations and 30 deaths; and
  • 571 cases in domestic settings (all allegations).

In comparison, during FY 2006, OIG closed 2,210 allegations and 143 death cases:

  • 1,309 cases in DD settings - 1,198 allegations and 111 deaths;
  • 490 cases in MH settings - 458 allegations and 32 deaths; and
  • 554 cases in domestic settings (all allegations).


The three tables that follow show detailed breakouts of findings by setting for cases OIG closed during FY 2007. Abuse and neglect substantiations are listed separately, as are death cases that were closed without any allegation or suspicion of abuse or neglect.

The first two of these tables also show if an "other issue" was cited. Even if not substantiating an allegation, OIG may still identify other administrative issues that require action (see Strategic Objective I.E.1). During FY 2007, OIG identified issues in 435 cases that were not substantiated, which is 54% more than the 283 in FY 2006 and more than double the 209 in FY 2005. This is an indication of OIG's commitment to the safety and well-being of individuals receiving services.

Table 6 - Rule 50, Allegations and Death Cases Closed in FY 2007, Mental Health Services Only
Facility or Agency program Abuse substan-tiated Neglect substan-tiated Other issue only Not substan-tiated Findings totals Closed death cases(1)
Alton (civil) 1 0 2 25 28 0
Alton (forensic) 0 0 1 44 45 0
Chester 2 2 9 119 132 2
Chicago-Read 0 0 5 22 27 1
Choate (2) 1 0 1 34 36 1
Elgin (civil) 1 0 2 11 14 1
Elgin (forensic) 2 1 11 36 50 1
Madden 1 1 5 15 22 1
McFarland (3) 2 0 1 16 19 2
Singer 4 1 9 26 40 2
Tinley Park 0 1 3 14 18 0
Facility subtotals 14 6 49 362 431 11
Residential 8 2 18 29 57 17
NonResidential 5 1 7 22 35 2
Agency subtotals 13 3 25 51 92 19
Rule 50 -
MH Totals
27 9 74 414 523 30

(1) Two facility death cases were closed with other issues and one was closed not substantiated, and one agency death case was closed not substantiated.

(2) Mental health units only.

(3) In FY 2007, there were no closed cases on the forensic unit.

Table 7 - Rule 50 Allegations and Death Cases Closed in FY 2007, Developmental Disabilities Services Only
Facility or Agency program Abuse substan-tiated Neglect substan-tiated Other issue only Not substan-tiated Findings totals Closed death cases
Choate (2) 1 2 3 88 94 1
Fox 0 2 1 3 6 2
Howe 1 5 15 123 144 5
Jacksonville 2 1 8 104 115 5
Kiley 4 3 15 24 46 2
Ludeman 0 2 3 21 26 2
Mabley 2 1 5 15 23 1
Murray 6 0 7 10 23 3
Shapiro 5 1 5 22 33 10
Facility subtotals 21 17 62 410 510 31
Residential 70 37 197 314 618 72
NonResidential 41 13 99 142 295 6
Agency subtotals 111 50 296 456 913 78
Rule 50 -
DD Totals
132 67 358 866 1423 109

(1) Two facility death cases were closed not substantiated. One agency death case was closed withsubstantiated neglect and another was closed with other issues.

(2) Developmental disability units only; includes one not substantiated from the forensic unit.

Table 8 - Rule 51 (Domestic Settings) Allegations Closed in FY 2007
Disability Type Abuse substan-tiated Neglect substan-tiated Exploitation substan-tiated Refused consent Not substan-tiated Findings totals (3)
DD 54 33 1 66 154 308
PD 10 5 2 70 94 181
MH 4 4 4 31 39 82
Rule 51 Totals 68 42 7 167 287 571

(3) Excludes complaints that were not reportable per the administrative rule.


Substantiations

As the three tables above show, during FY 2007, OIG substantiated abuse or neglect by staff in 353 cases, nearly 10% more than the 322 cases last year and 20% more than the 309 cases in FY 2005. Abuse continues to be substantiated more than neglect, and both were substantiated more frequently in community agencies (see table).

Table 9 - Substantiated Abuse and Neglect by Setting, FY 2007
Location Abuse substantiated Neglect substantiated Total substantiated
DHS facilities 35 23 58
Community agencies 24 54 178
Domestic settings 68 42 117*
Totals 227 119 353*

*

includes 7 substantiated exploitation cases

Substantiation rates

The percentage of substantiated cases - that is, dividing the number of all cases closed into the number closed as substantiated abuse or neglect - provides a rate that allows comparisons across locations and fiscal years despite differences in actual counts.

The table that follows gives substantiation rates for the past four fiscal years and by setting.

Table 10 - Substantiation Rates by Fiscal Year and Setting
Fiscal Year Rule 50 - Facility Rule 50 -Agency Rule 51 - Domestic Overall totals
FY 2004 7.2% 19.1% 13.3% 12.6%
FY 2005 4.5% 18.4% 21.9% 13.5%
FY 2006 6.3% 17.5% 19.9% 14.4%
FY 2007 5.9% 16.2% 19.3% 14.0%


This table shows that overall rates have not fluctuated much from year to year, but rates across settings remain significantly different. OIG attributes the lower substantiation rate in facilities to the higher percentage of clearly unfounded cases being reported from the DHS facilities; OIG attributes the higher substantiation rates in domestic cases to the lower standard of proof required in the statute for domestic abuse/neglect/exploitation ("credible evidence" standard in domestic cases compared to a "preponderance of the evidence" standard for cases at facilities and agencies).


I.D.4

Benchmark I.D.4 - Refer substantiated domestic cases for service plan development.

FY 2007 Result - OIG referred all 117 individuals to the divisions.


When OIG substantiates a domestic abuse case, OIG is required by law to refer the alleged victim to the appropriate division in DHS for development of a service plan. After OIG refers the case to the division, the individual has the legal right to refuse to consent to the service plan.

Of the 117 allegations of abuse, neglect, or exploitation that OIG substantiated during FY 2007, the alleged victim in 76 cases was referred to the Division of Developmental Disabilities for a service plan, the alleged victim in six cases was referred to the Division of Mental Health, and the alleged victim in 35 cases was referred to the Division of Rehabilitation Services. The alleged victim has the right to refuse any services from DHS or any other entity. As shown in the table above, the majority of service plan referrals every year has been to the Division of Developmental Disabilities.

Table 11 - Service Plan Referrals from Substantiated Domestic Cases
DHS Division FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007
Developmental Disabilities 45 42 45 44 83 62 76
Rehabilitation Services 20 24 11 11 29 42 35

Mental

Health

8 2 2 5 6 6* 6
Totals 73 68 58 60 119 110 117

* OIG referred an additional two individuals to DMH whose primary referral was to another division.


Initiative E: Monitor implementation of Written Response actions.


I.E.1

Benchmark I.E.1 - 50% of approved Written Responses received by case closure.

FY 2007 Result - OIG received 40% of approved Written Responses timely.


The statute requires that, whenever OIG substantiates abuse, neglect or finds other administrative issues during an investigation, the facility or agency where the incident occurred is required to provide a response in writing. This "Written Response" must address the actions that have been or will be taken to protect the resident or patient from abuse or neglect, prevent reoccurrences, and eliminate problems identified during the investigation. The Written Response must include the projected implementation dates for all such actions.

Once OIG has sent the completed report, the agency or facility has 30 calendar days to submit a Written Response before the case is closed. Written Responses must be submitted to the appropriate DHS division, which reviews them for the DHS Secretary. The division may need to follow up with the agency or facility to submit a Written Response or to augment the actions planned. So, OIG allows another 30 calendar days for the division's approval of the Written Response.

When a Written Response is finally approved, the division sends it to OIG. Thus, OIG knows when each approved Written Response is due - 30 days after case closure - but does not know at what point in the approval process it is.

Patterns/Trends
More Written Responses

OIG is requiring a Written Response in an increasing number of cases. In cases closed during FY 2007, OIG required 671 Written Responses, a 36% increase over FY 2006. More were required in cases at community agencies (500, a 42% jump) than at facilities (171, a 20% rise).

Of the 500 Written Responses required of agencies during FY 2007, 459 were at DD agencies and 41 at MH agencies, which mirrors the overall breakout by disability type among allegations reported to OIG. Of the 171 required of facilities during FY 2007, 71 were at DD facilities and 100 at MH facilities.

More approvals received late

Despite the additional 30 days for the division's approval, not all approved Written Responses are received in OIG timely. The number of approvals that OIG received late has continued to rise. During FY 2007, a full 30% of the required Written Responses (203 of 671) were received by OIG as approved well after the 30 days after closure, and another 30% still had not been received at all more than 45 days after that. This rate of 60% late during FY 2007 compares to 56% late during FY 2006 and 35% late during FY 2005.

Of the 459 cases that required a Written Response from DD community agencies during FY 2007, 167 (36%) were received as approved late and 183 (40%) were already late and not yet received. That is, out of 459 required DD agency Written Responses, 76% were not received as approved within 30 days after case closure. DD agencies accounted for 68% of all Written Responses required during the fiscal year, but they accounted for 82% of those that were late and 92% of those that were still not received by OIG 45 days after the end of FY 2007. This difference indicates that the delay appears to be in receiving the divisions' approval, rather than the agencies' response rate. OIG has been working with the divisions to speed receipt of approvals.

More issues cited

Each Written Response can have multiple issues cited with multiple actions taken for each issue. During FY 2007, a total of 671 separate issues were cited in the 471 cases on which OIG has received an approved Written Response.

OIG categorizes the issues cited in Written Responses into 38 different types, and six of those types are substantiated allegations: physical abuse, sexual abuse, mental abuse, domestic exploitation, neglect, and egregious neglect. During FY 2007, these substantiations accounted for 165 issues cited, similar to FY 2005's count of 170 and FY 2006's count of 176.

The table below shows the counts and percentages for substantiations and other common issues over the past three fiscal years. The drop in substantiations for FY 2007 is due in part to the longer time it has taken recently to receive approved Written Responses. Note also that the FY 2005 and FY 2006 counts and percentages may be different than reported in those years' annual reports, due to approved Written Responses received long after the end of the respective fiscal year.

Table 12 - Frequent Issues in the Approved Written Responses by Fiscal Year*
Issues FY 2005 Count FY 2005 Percent FY 2006 Count FY 2006 Percent FY 2007 Count FY 2007 Percent
Substantiations 181 35.7 196 29.5 165 24.6
Failure to report 89 17.6 138 20.8 160 23.8
Late reporting to OIG 51 10.0 39 5.9 57 8.5
Inappropriate interaction 47 9.3 53 7.9 46 6.9
Unit/client monitoring 22 4.3 32 4.8 25 3.7
Nursing practices 18 3.6 35 5.3 37 5.5
Habilitation/Treatment plan 6 2.4 15 5.1 28 3.3
All other issues 93 17.1 157 20.7 153 23.7
Total issues 507 100% 665 100% 671 100%

* Includes all approved Written Responses received through August 20, 2007.


In each fiscal year, a substantiation was the most frequent issue cited. The continuing rise in OIG's citations for failure to report, nursing practices and other issues, however, is evidence that OIG is citing an increasing number of other issues. Thus, OIG is going beyond substantiating the allegation and is aiming at preventing, not just reacting to, abuse and neglect.

More actions taken

In response to these 671 issues cited in FY 2007's Written Responses, the agencies and facilities took 889 actions to help prevent recurrences and eliminate the problems identified. OIG categorized the actions taken into 18 different types. The most frequent actions taken were:

  • Retraining of an employee, 17.7% (157 of 889);
  • Training of a group of staff, 17.0% (152 of 889);
  • Discharge of an employee, 15.3% (136 of 889, plus another 51 resignations); and
  • Suspension of an employee, 7.3% (65 of 889).

The 889 actions that were taken in FY 2007 is more than in any previous year, showing agencies and facilities are taking more actions to prevent recurrence of problems found.


I.E.2

Benchmark I.E.2 - In 20% sample, 100% are in compliance.

FY 2007 Result - Of 109 cases (20% sample), 100% were in compliance.


OIG is statutorily responsible for reviewing a sample of approved Written Responses to ensure that the corrective actions identified by the community agency or DHS facility were actually implemented as approved by the respective DHS division. The goal of these "compliance reviews" is to provide assurances regarding overall implementation of actions aimed at protecting individuals, preventing recurrence, and eliminating problems identified. For FY 2007, OIG again set a strategic benchmark of working with the agencies and facilities to ensure implementation of all actions identified in a random 20% selection.

Process

OIG's conducts the compliance reviews monthly. The process begins with a random selection of approved Written Responses received during the previous month. OIG's two Compliance Reviewers conduct an initial review of each selected Written Response and related documentation submitted, developing a plan for checking implementation. This plan is then reviewed in a joint meeting with supervisors and a database manager, to ensure quality, consistency and accuracy.

If additional documentation - e.g., training records, revised policies, or verification of discipline - is necessary, the assigned Compliance Reviewer contacts the agency or facility by phone and in writing to obtain it. If a site visit is necessary to review documentation, interview staff or observe operations, the visit is usually scheduled in advance with the authorized representative or OIG liaison.

Upon completion of the compliance review, OIG sends a letter to the authorized representative indicating whether the agency or facility is in compliance or not. The result is then discussed during the compliance review meeting the following month. Thus, compliance reviews for a fiscal year examine approved Written Responses received during May 1 through April 30.

FY 2007 results

During FY 2007, OIG conducted 109 compliance reviews on a randomly selected 20% sample of the 549 OIG approved Written Responses received May 1, 2006 through April 30, 2007. Of these 109 compliance reviews:

  • 28 necessitated on-site visits for multiple interviews, document reviews, or observation;
  • 7 involved phone contacts for additional information or a single interview;
  • 74 required reviews of documentation only.


OIG selects random samples separately from agencies' and facilities' approved Written Responses. Of the 109 Written Responses randomly selected for FY 2007 compliance reviews:

  • 75 were selected from the 387 approved Written Responses from agencies; and
  • 34 were selected from the 162 approved Written Responses from facilities.


All 109 compliance reviews found the agency or facility had implemented the corrective actions identified in the approved Written Response. In one of the reviews, the facility was initially found to have failed to implement the corrective actions it had identified on the approved Written Response. However, after OIG followed up further, the facility took the action as planned.

Issues and actions

Written Responses sometimes cite more than one issue and frequently identify multiple actions for single issues.

The most common issues in Written Responses checked during the 75 compliance reviews at agencies in FY 2007 were a failure to report an allegation, an employee's inappropriate interaction with an individual, or late reporting to OIG. The most common issues in Written Response actions checked during the 34 compliance reviews at facilities in FY 2007 were a failure to report, substantiated mental injury, or late reporting to OIG.

The most common actions taken by agencies in Written Responses checked during the FY 2007 compliance reviews were group training of staff or the re-training or discharge of an employee. The most common actions taken by facilities in Written Responses checked during FY 2007 compliance reviews were the re-training, suspension, or discharge of an employee.

Follow-up through Written Response compliance reviews has reinforced to the agencies and facilities the importance of following through on corrective actions, to take actions to eliminate opportunities for abuse and neglect to occur, and to improve the safety of residents.


Initiative F: Refer names to the IDPH Health Care Worker Registry.


I.F.1

Benchmark I.F.1 - Refer 100% of appropriate names to the Health Care Worker Registry.

FY 2007 Result - OIG referred all 66 appropriate names to the Registry.


State law requires OIG to report to the Illinois Department of Public Health's Health Care Worker Registry (formerly the Nurse Aide Registry) the identity of any employee with a substantiated finding of physical abuse, sexual abuse or egregious neglect of an individual who is receiving services in a program under OIG's investigative jurisdiction. Once an individual is placed on the Registry, he/she is legally prohibited from working in any health care setting in Illinois.

Reconsiderations, Grievances and Appeals

An employee has three avenues for avoiding having OIG report his/her identity. First, whenever OIG substantiates a case, an accused person has 15 working days to request OIG reconsider the finding. The person must submit information that was not originally considered and that could affect the finding of the case. If OIG does reverse the substantiation, the person's identity will not be referred to the Registry.

Second, the employee may file an employee grievance or other internal facility/agency process. If the grievance results in a discharged employee being returned to work, that employee's identity will not be referred to the Registry. These grievances are not tracked by OIG, however, and even when OIG knows that a grievance is not yet decided, OIG is still required by law to refer the identity to the Registry if more than three months have passed since the grievance was filed.

Third, once a person is notified that OIG intends to refer his/her name to the Registry, that person may file a "50.90" appeal with the DHS Bureau of Administrative Hearings. This appeal is not to request a change in the finding. Rather, it is intended to assess whether or not the person's identity should go on the Registry based on the substantiated act or omission.

After a person's identity has been referred to the Registry, he/she may petition once a year to have it removed. This is a "50.100" appeal, and it is decided on the basis of evidence of the employee's rehabilitation, training, education, ability to perform duties in the public interest, and conduct since his/her name was referred, as well as his/her candor and forthrightness in presenting information for the appeal. The appeal typically involves OIG conducting an investigation into these issues.

FY 2007 Referrals

In FY 2007, a total of 66 employees were substantiated to have committed a Registry-reportable offense, and OIG referred the identities of all 66 employees to the Health Care Worker Registry. This total is 21% fewer than the 84 during FY 2006, but it is 6% more than the 62 during FY 2005 and 22% more than the 54 during FY 2004.

As in each of those years, most of the identities referred were of agency employees (51 of 66, or 78%). Of all 66 employees:

  • 52 (79%) were for substantiated physical abuse, which was again the leading reason for referral. Physical abuse accounted for 71 (84%) of FY 2006 referrals, 57 (92%) of FY 2005 referrals, and 48 (89%) of FY 2004 referrals.
  • 12 (18%) were for substantiated sexual abuse, which also accounted for twelve (14%) of FY 2006 referrals, five (8%) of FY 2005 referrals, and five (9%) of FY 2004 referrals.
  • 2 (3%) were for substantiated neglect that OIG determined to be egregious. This reason accounted for one referral in FY 2006, none in FY 2005, and one in FY 2004.
Appeals

OIG works closely with the DHS Bureau of Administrative Hearings and the Department of Public Health to refer names, monitor appeals, attend and testify in hearings, and request removal of names from the Registry.

For 50.90 appeals (requests to not be referred to the Registry) in FY 2007:

  • 30 appeals were filed; 21 of these and 17 pending from FY 2006 (a total of 38) were decided in FY 2007;
  • Of these 38 decisions, 18 were referred to the Registry and 20 were not referred; and
  •  Of those 20 that were not referred,
    • fourteen were because the person won the appeal,
    • four were "stipulations" agreed to prior to hearing (see Strategic Objective II.E.1),
    • one was because the Civil Service Commission overturned the discharge, and
    • one was because a grievance resolution reduced the charge to a lesser offense that is not Registry-reportable.

For 50.100 appeals (requests to be removed from the Registry) in FY 2007, a total of ten persons filed an appeal: six by community agency employees, and four by facility employees. Of those ten employees, four were removed from the Registry, four had their appeal dismissed, and two had the decision still pending at the end of FY 2007.


Initiative G: Include facility staffing ratios in the Annual Report.


I.G.1

Benchmark I.G.1 - Include direct care staffing ratios for all facilities.

FY 2007 Result - Table of direct care staffing ratios is included.


The table on the following page presents the information on direct care staffing that is statutorily required. The columns are:

  • Budgeted Beds - Before the start of each year, DHS budgets for the expected number of individuals who will need services in each facility on an inpatient basis. This number is a way to compare facility sizes, although the actual count of patients may fluctuate daily.
  • On-Books Bed-Days - Another way to count individuals is to add up the number of days that individuals were receiving services. That is, multiplying the number of individuals who received services times the days they were "on the books" as being served.
  • Individuals Served - A third way to count individuals is to count only the number of individuals who received services at the facility at least once - and count them only once, even if they were admitted more than once.
  • Direct Care Staff - Some facility staff do not provide services directly to individuals; these do not count as direct care. Other staff work part-time, so to calculate a number of direct care staff, DHS converts the total count to "full-time equivalent" direct care staff.
  • Staffing Ratio - The count of individuals on the facility's books on June 30, 2007, divided by the "full-time equivalent" of direct care staff results in a ratio of direct care staff to patients, which is called the "staffing ratio."
Table 13 - Census and Direct Care Staffing Ratios at DHS Facilities, June 30, 2007
Facility Budgeted Beds On-Books Bed-Days (1) Individuals Served (2) Direct Care Staff (3) Staffing Ratio (4)
Choate DC 171 64,542 207 246.57 1.45
Fox DC 142 53,969 152 165.15 1.16
Howe DC 367 142,883 404 543.10 1.48
Jacksonville DC 237 88,962 270 312.50 1.32
Kiley DC 228 88,100 254 320.00 1.40
Ludeman DC 383 145,830 419 488.50 1.28
Mabley DC 91 33,122 96 127.44 1.40
Murray DC 334 123,350 358 380.55 1.14
Shapiro DC 596 220,411 624 903.99 1.52
DD subtotals 2,549 961,169 2,784 3,489.80 1.35
Alton MHC 127 45,396 352 174.40 1.37
Chester MHC 286 104,331 451 355.57 1.24
Chicago-Read MHC 130 46,631 1,556 200.50 1.54
Choate MHC 80 26,339 513 106.53 1.33
Elgin MHC 370 135,014 1,296 500.20 1.35
Madden MHC 133 45,411 3,034 201.15 1.51
McFarland MHC 115 42,342 652 135.99 1.18
Singer MHC 64 26,004 637 100.67 1.57
Tinley Park MHC 54 24,136 1,476 117.10 2.17
MH subtotals 1,359 495,604 9,967 1,892.11 1.47

(1) The total number of days (from admission to discharge) for all individuals residing in the facility.

(2) An unduplicated count of all individuals residing in the facility during the fiscal year.

(3) The number of direct care staff, but part-time staff are counted in full-time equivalents.

(4) The direct care staff to patient ratios on June 30, 2007.


Priority II - Streamlining processes and procedures

Table 14 - Detailed Performance Scorecard for Priority II Strategic Objective: Streamlining processes and procedures
Initiative Benchmark Measure Performance Measurement Performance Result Performance Trend (and 3-year trend*)
A. Ensure all abuse /neglect allegations are investigated.

1) By 1/31/07, save non-reportable calls in OIG database.

2) Review and revise directives by 6/30/07.

3) Begin quarterly reviews by 1/31/07.

1) Database revised as of 12/8/06.


2) 16 directives revised 2/23/07.


3) Quarterly reviews begun 1/4/07.

1) 100%


2) 100%


3) 100%

1) N/A


2) N/A


3) N/A

B. Address OIG interview timeliness and documentation. 1) Revise directive on OIG interviews by 6/30/07. 1) Revised two OIG directives effective 2/23/07. 1) 100% 1) N/A
C. Facilitate access to OIG database and case management.

1) Add second case button by 1/31/07.

2) Create an off-line version by 6/30/07.

3) By 6/30/07, get 38 updated computers.

1) Button added on 12/8/06.

2) Case program distributed.

3) Got 41 updated computers in 5/07

1) 100%


2) 100%


3) 108%

1) N/A


2) N/A


3) N/A

D. Reduce days required to complete OIG investigations.

1) Average 50 days per case.

2) Complete 80% within 60 days.

3) Address existing headcount issues.

4) Intake complete 50 unfounded cases.

5) Bureau chiefs do 50 unfounded cases.

6) Monitor case review timeliness.

7) Assign OIG staff to monitor agency investigations.

1) Averaged 46 days per case.

2) Completed 71% within 60 days.

3) Filled positions as available.

4) Intake completed 61 cases.

5) Bureau chiefs did 55 such cases.

6) Entering case review dates.

7) OIG investigators assigned beginning 7/1/06.

1)108%


2) 89%


3) 100%


4) 122%


5) 110%


6) 100%


7) 100%

1) Improvement


2) No change


3) N/A 


4) Improvement


5) Improvement


6) N/A


7) N/A

E. Streamline Registry appeals hearing process.

1) By 12/31/06, find process to stipulate non-referral.

2) Train OIG staff on testifying, by 6/30/07.

1) Stipulation process finalized 9/11/06.

2) Training done 3/30/07, 4/5/07.

1) 100%


2) 100%

1) N/A


2) N/A

F. Draft legislative revisions to update statute.

1) By 3/1/07, draft bill to move OIG to DHS chapter of statutes.

2) By 3/1/07, draft bill to deter reporting of false allegations.

3) By 3/1/07, draft bill to avoid guardian ad litem fees.

4) By 6/30/07, draft revisions to Rule 50, as needed.

1) SB 1368 filed on 2/9/07, signed on 8/28/07.

2) SB 1364 filed on 2/9/07; stalled on third reading.

3) SB 452 filed on 2/8/07, signed on 8/23/07.

4) None needed yet, as the statutory definitions have not changed.

1) 100%


2) 90%


3) 100%


4) N/A

1) N/A


2) N/A


3) N/A


4) N/A

* Three-year trend, where applicable, covers FY 2005 through FY 2007.

Summary for Priority II: Streamlining processes and procedures

This section displays results for this FY 2007 strategic objective and related initiatives by specific benchmark measure. It summarizes OIG performance during the fiscal year and the narrative that follows provides relevant detail about each benchmark.

FY 2007 Summary for Priority II Strategic Objectives
Related Initiatives Total Benchmarks Average Results Targets Met
6 19 101.4% 90.0%

Related initiatives for this strategic objective:

  1. Ensure all abuse/neglect allegations are investigated
  2. Address OIG interview timeliness and documentation
  3. Facilitate access to OIG database case management
  4. Reduce days required to complete investigations
  5. Streamline Registry appeals hearing process
  6. Draft legislative revisions to update statute

Initiative A: Ensure all abuse/neglect allegations are investigated.


II.A.1

Benchmark II.A.1 - By January 31, 2007, save non-reportable calls in the database.

FY 2007 Result - OIG database was revised December 8, 2006, to include these.


Since OIG's 24-hour Hotline number (800-368-1463) is posted in facility and community agency program locations and is widely publicized, OIG receives many calls about complaints that are "not reportable"; that is, the complaints do not report or alleged something that would meet the definitions in Rule 50 or Rule 51. Further, facility and agency staff are required by law to report all allegations - failure to report is now a Class A misdemeanor - and they are prohibited from screening any allegations, regardless of the apparent credibility.

Therefore, OIG's Hotline receives "Non-Reportables" - calls in which OIG determines the alleged action to be outside the definitions in Rule 50 and Rule 51. When a Hotline investigator determines that the complaint is outside the rules' definitions, he/she documents the information and tells the caller the reason why.

OIG has long retained this written documentation of these complaints but did not enter them into its database. Hotline investigators recorded the Non-Reportable's information on a simple word processing form, which was then reviewed and approved by a second reviewer. Following some internal discussions and spurred on by a recommendation by the Auditor General, OIG set a goal of revising the Hotline's intake process to save Non-Reportables in the database. Development and testing was conducted during the fall and, on December 8, 2006, revised forms that allowed saving these calls in the database were imported.

Now, all non-reportables are saved in the OIG database and each continues to have a second review. These Non-Reportables are also then listed along with reportable allegations in future cases involving the same person.

In FY 2007, a total of 941 Non-Reportable complaints were recorded by OIG's Hotline investigators, 366 of these before the database change and 575 afterwards.


II.A.2

Benchmark II.A.2 - By June 30, 2007, review and revise OIG directives.

FY 2007 Result - OIG reviewed all directives and revised 16 by February 23, 2007.


To ensure that its directives better reflected or improved current investigative practices, OIG formed an OIG Directives Review Committee in August 2006. The committee reviewed all of OIG's Rule 50 investigative directives, which are in Section II of the OIG Directives Manual. Comments and recommendations made by the auditors were also considered.

The committee proposed revisions to 16 directives, and these were approved by the Inspector General on February 23, 2007. The 16 revised directives were distributed to all OIG staff on February 26, 2007. The revisions included substantive changes in procedures for OIG Hotline coverage, law enforcement involvement, assignment of investigations, representation at investigatory interviews, and investigations involving medical issues.


II.A.3

Benchmark II.A.3 - Begin quarterly case reviews by January 31, 2007.

FY 2007 Result - OIG began Quarterly Case Reviews on January 8, 2007.


The Illinois Auditor General, during his latest biennial audit of OIG, expressed some concern about OIG's consistency in findings, particularly in "unfounded" and "unsubstantiated." Rule 50 defines unfounded as meaning that the investigation found no credible supporting evidence for the allegation. On the other hand, if the investigation does find some credible supporting evidence, but it is less than a preponderance, Rule 50 indicates that the case is unsubstantiated.

OIG's Deputy Inspector General reviews all substantiated cases, which constitute approximately 12% of all OIG investigations. Since OIG investigated over 2,500 investigations during FY 2007, it would be impossible for one person to review all of the reports. In response, OIG developed an alternate approach to ensuring consistency among unfounded and unsubstantiated.

Beginning in January 2007, the Deputy Inspector General began a quarterly review process. Each quarter, the Deputy Inspector General and a designated bureau chief review a sample of unsubstantiated and unfounded cases from each investigative bureau from the previous quarter. The reviewers examined the cases to determine whether the investigative bureaus had employed a consistent analysis of the criteria for such classification and were reaching the same conclusions when presented with similar evidence.

The sample, drawn randomly by the database, includes cases involving the same type of allegation. For example, in reviewing cases from the second quarter of FY 2007, the reviewers looked at unfounded/unsubstantiated neglect cases. The process was repeated for physical abuse cases from the third quarter of FY 07. Neither review revealed inconsistencies in interpretation among the investigative bureaus.


Initiative B: Address OIG interview timeliness and documentation.


II.B.1

Benchmark II.B.1 - By June 30, 2007, revise directive on OIG interviews.

FY 2007 Result - Two directives were revised effective February 23, 2007.


During FY 2007, OIG reviewed its investigative directives to ensure that they clearly address the critical need for starting investigations promptly and documenting them adequately. OIG revised its directives on the initial assignment of the investigation (INV 02-007) and on the conduct of the investigation (INV 02-017); both were approved on February 23, 2007. The revised directives streamline and standardize expectations.

Process

Once a bureau receives a new intake from the OIG Hotline, the bureau chief assigns the case within one working day, absent extenuating circumstances. The investigator and his/her supervisor develop an investigative plan, which the bureau chief must approve within three working days of assignment. This ensures that cases are begun promptly and the initial approach is documented.

The bureau chiefs had previously been required to designate which interviews were "critical" and to ensure that those interviews were conducted within five working days of the plan's approval. However, OIG found that such designation did not contribute to more timely case completion. In addition, since alleged perpetrators are usually interviewed toward the end of an investigation, it was difficult to conduct all "critical" interviews within the time frame. Further, investigators could not reasonably expect to conduct timely interviews of involved persons not discovered until later.

The bureau chiefs employ additional approaches that together are more effective at ensuring that cases get completed in a timely manner. After approving an investigative plan, the bureau chief uses a "Task Function" in the DHS email system to automatically identify cases that have been open for twenty working days. When that happens, the bureau chief discusses the case with the assigned investigator, and they determine what the evidence is indicating at that point. If the case is likely to be unfounded or unsubstantiated, they develop a plan to close the case as quickly as possible. For all other cases, they identify tasks that remain, formulate an approach to completing the investigation, and identify a projected completion date.

OIG firmly believes that the initial investigative plan, more direct case monitoring, and the twenty-day case tracking, along with the closure of cases with the assistance of Intake and agency investigators, are more likely to help investigators reduce the completion time. OIG also has a standard form for documenting interviews but allows investigators flexibility in writing the summary to reflect the actual interview. Investigators must be able to exercise sound discretion to conduct investigations as they see fit under the circumstances, as long as the cases are completed in a timely manner.


Initiative C: Facilitate access to OIG database case management.


II.C.1

Benchmark II.C.1 - Add second case selection shortcut button by January 31, 2007.

FY 2007 Result - A new shortcut was added on December 8, 2006.


OIG investigators enter the actions that they take on a case into the OIG database. From the main database screen, the investigator clicks on a button, types in the case number, and then enters investigative case actions. To enter case actions on a second case, however, the investigator had to first exit to the main screen. Investigative supervisors also do entry - reviewing the investigator's actions in real-time, providing direction, and entering status notes - and have been able to update only one case at a time without going back to the main screen.

OIG determined that eliminating the extra step for the investigators and their supervisors would thus speed investigative case action entry. Thus, OIG set an FY 2007 strategic benchmark of revising the database by the end of 2006 to include a new button that would enable the investigators and supervisors to select a second case without returning to the main screen. Following development and testing during November, on December 8, 2006, OIG imported an upgraded database form that has a second case button on the investigative case actions screen.


II.C.2

Benchmark II.C.2 - By June 30, 2007, use off-line version for case action entry.

FY 2007 Result - OIG created the process and finished training on April 5, 2007.


In FY 2006, OIG began recording in the database the steps taken during an investigation. The database changes worked well but slowly, due to the increased sophistication and complexity of the database. Further, the investigative steps could be entered only while the user was connected to the network. These two problems hindered case action entry.

To address those issues, OIG sought to create a stand-alone version of the program, allowing investigators to enter investigative case actions quickly, even while not connected to the database. In January 2007, OIG completed a program that allows a non-networked user to save case actions to a small password protected database on the user's hard drive. Once the user is connected to the network, these case actions are automatically uploaded to the OIG database.

Using this program to add case actions directly to the OIG database resulted in faster case entry, since the program bypasses more system-intensive tasks the main database requires. Thus, as a side benefit, the program resolved the second problem as well. Two training sessions for OIG staff were held on March 30, 2007 and April 5, 2007, and the program was deployed on April 3, 2007.


II.C.3

Benchmark II.C.3 - By June 30, 2007, obtain 38 updated computers for staff.

FY 2007 Result - OIG received 41 updated computers by May 18, 2007.


To improve timeliness of its investigations by speeding access to the OIG database and real-time case management system, OIG sought better laptop and desktop computers. Nearly all of OIG's existing computers were running on obsolete operating systems (Windows 95 or Windows 98), had limited working memory (RAM), and had slow processors, all of which caused delays in entering case information and drafting case documents.

In November 2006, DHS agreed to provide ten new tablet computers and OIG ordered 27 upgraded desktop computers and one laptop computer; DHS later offered three additional table computers. As of May 18, 2007, OIG had received all 41 computers, each with Windows XP operating system, more working memory, and a much faster processor. The 41 computers were distributed across OIG, and now 22 staff have only outdated computers (another nine outdated computers are still used as secondary computers). While some installation problems remain with the tablet, OIG staff report less time doing data-entry and writing reports and less time lost due to required repairs.


Initiative D: Reduce days required to complete OIG investigations.


II.D.1

Benchmark II.D.1 - Average 50 working days per case.

FY 2007 Result - OIG averaged 45.8 days per case during FY 2007.


Rule 50 expects that, absent exceptional circumstances, investigations should be completed within 60 working days. During FY 2007, OIG took substantial steps toward improving timeliness of its investigations. In addition to steps with specific benchmarks, which are discussed below in II.D.3 through II.D.7, OIG has done the following.

  • By July 1, 2006, began assigning all investigations using a "task" function in the e-mail system that alerts the supervisor when a case reaches 20 days old, so the supervisor can follow-up, if the case has not yet been completed;
  • Also by July 1, 2006, in order to avoid duplication of investigative efforts, OIG investigators began relying more on interviews conducted by trained facility/agency investigators;
  • Beginning in November 2006, established regular meetings of the investigative bureau chiefs to discuss caseload issues and renewed a commitment to temporarily reassign investigations when caseloads rise; and
  • On January 12, 2007 revised OIG Directive INV 02-019 to further standardize a process of 30-day and over-45-day reviews for all active OIG investigations.


The result has been an improvement in timeliness. During FY 2003, OIG's Rule 50 investigations took an average of nearly 60 days per case, meeting the goal in the rule. This average increased to 85 days per case in FY 2004, but then dropped to 48 days per case in FY 2005 and 53 days per case in FY 2006. During FY 2007, OIG's Rule 50 investigations averaged 45.8 days per case and, in the fourth quarter of the year, only 44.0 days per case.


II.D.2

Benchmark II.D.2 - Complete 80% of Rule 50 cases in 60 working days.

FY 2007 Result - OIG completed 71% of these cases within 60 days per case.


While OIG has averaged under 60 working days per completed OIG Rule 50 investigation, a few cases may be delayed - an accused employee may be out on extended leave, a death case may require an autopsy and coroner's inquest, test results on evidence may be delayed, or the case may initially be investigated by the Illinois State Police and then reassigned to OIG months later. During FY 2006, 71% of OIG's completed Rule 50 investigations were completed within 60 days.

As OIG began working even harder to average less than 60 days per completed investigation, it became evident that these older cases required greater attention. Thus, OIG also focused on promptly completing cases that had been delayed. During FY 2007, again 71% of OIG's completed Rule 50 investigations took longer than 60 days.


II.D.3

Benchmark II.D.3 - Address existing investigator headcount issues.

FY 2007 Result - By June 30, 2007, OIG had two investigative vacancies.


Thanks to a streamlined process adopted by CMS and DHS human resources, OIG has seen a reduction in the time required for filling vacant positions. However, the process can still take up to three months. Throughout FY 2007, OIG had an average of two to three vacant investigative positions, and OIG anticipates that rate to continue due to ongoing turnover. Some positions remained vacant for more than three months, but OIG had filled all but two recent investigative vacancies by June 30, 2007. Leaves of absences are not included in counts of vacant positions. During the course of FY 2007, five investigative team members were on leaves of absence more than thirty days.

While vacancies have occurred, reducing the number of OIG investigators, the number of OIG investigations has continued to climb. Thus, the investigative bureaus have experienced an increase in their caseloads: OIG investigators must handle more cases and still try to close cases within sixty working days. Other factors, such as a decreasing number of community agencies that are willing to have staff trained and approved by OIG as investigators, may increase the work required of OIG investigators.

This manpower shortage is particularly acute in the Domestic Abuse Project, which currently has three investigators and an investigative team leader to cover the entire state of Illinois. At the start of FY 2007, the DAP investigators averaged 15.8 open investigations each; by the end of the fiscal year, they averaged 40.5 open investigations each. Unfortunately, the workload for these investigators will surely increase in the face of the continued rise in domestic abuse cases that topped 700 for the first time in FY 2007.


II.D.4

Benchmark II.D.4 - Complete 50 unfounded cases by Intake investigators.

FY 2007 Result - Intake investigators handled 61 cases of recanted allegations.


Infrequently, someone will call the OIG Hotline to report an allegation but also report that the alleged victim "recanted" the allegation - that is, made the allegation and then indicated that the alleged incident did not happen. OIG does not want to ignore the initial claim, but is faced with expending valuable resources on an allegation that even the person who made it does not believe.

OIG thus developed a process to handle such "recants" and set a strategic benchmark to follow the process on at least 50 claims. According to the process, the Bureau of Hotline and Intake sends out the intake report to the appropriate bureau chief but notifies him/her that the allegation may have been recanted. The bureau chief then holds off on assigning the investigation for up to 24 hours, while the Bureau of Hotline and Intake requests the facility or agency to re-interview the alleged victim. This interview must be conducted by an facility or agency employee who is currently trained and approved by OIG to do investigations and who was not the person who heard the initial recant. If the alleged victim still recants the allegation, this investigator assists in producing a written statement that clearly identifies that the alleged victim admits to recanting the allegation and his/her reason for lying. The agency or facility then faxes the statement and other supporting documents to the OIG Bureau of Hotline and Intake for review. If the review determines that the allegation has in fact occurred, that bureau completes an investigative case report which recommends that, since the allegation has been recanted, the case be closed as unfounded.

During FY 2007, the Bureau of Hotline and Intake flagged 68 cases as potential recants. In five of those cases, the alleged victim did not recant the allegation during the re-interview and, in two others, the agency did not have an OIG-trained investigator available. The remaining 61 met the requirements of a recant and were closed as unfounded. These 61 cases were completed in an average of 2.07 days per case, limiting both the time a case remained open and the expenditure of OIG investigative resources.


II.D.5

Benchmark II.D.5 - Do 50 unfounded cases by bureau chiefs.

FY 2007 Result - Intake completed 55 cases during FY 2007.


As noted in other benchmarks, OIG has implemented several initiatives during FY 2007 to speed the case completion process. At the same time, OIG has also reinforced several practices to ensure that all the investigative bureaus employ the same approach. One example is in having bureau chiefs consistently complete investigative case reports on allegations that were clearly unfounded, thereby greatly streamlining the case completion. One benchmark that OIG set for FY 2007 was to have the bureau chiefs complete 50 clearly unfounded cases.

To reach this benchmark, OIG also encouraged the use of interviews conducted by OIG-trained and authorized agency investigators, as long as OIG is satisfied that the interview was complete and competently conducted. Investigators were allowed to use these interviews as well, which saves investigative time and avoids duplication of effort. In addition, OIG increased the use of telephone interviews when appropriate, which saves investigative time and travel.

As noted above, OIG's Intake investigators may close cases involving recanted allegations (see Strategic Objective II.D.4). Other allegations, although not recanted, clearly lack credibility. Thus, even when Intake investigators cannot confirm a recantation and so must assign the case to a bureau, the bureau chief may follow up with agency personnel to obtain the information necessary to establish a case as unfounded and close it rapidly. During FY 2007, the bureau chiefs in OIG's four Rule 50 investigative bureaus completed 55 cases that were unfounded.


II.D.6

Benchmark II.D.6 - Monitor case review timeliness.

FY 2007 Result - OIG now records each step in the case review process.


OIG investigators submit all draft investigation reports to review by investigative supervisors before the reports are completed. Unfounded and unsubstantiated cases are reviewed by an investigative team leader, if the bureau has one, and by the bureau chief. Substantiated cases are also reviewed by the Deputy Inspector General. All approved cases are mailed out by the investigative bureau.

To monitor timeliness through this review process, OIG now tracks each step in the process. When submitting a case for review, the investigator still inputs a case action into the database, recording the date the draft report was submitted. However, as of November 2006, each person who reviews or works on the case is recorded as well. If an investigative team leader gives the draft report to the bureau chief, it is recorded in the database. If a case is substantiated, and so the bureau chief forwards it to the Deputy Inspector General for review, the bureau chief must record this into the database, too. When the Deputy Inspector General reviews the draft case report and approves it for completion, this is recorded as well. Any investigative supervisor may return it for further investigative activity or revision and, if so, the return is recorded in the database.

As a result, the database is able to identify exactly where in the review process a case is at any point in time. Further, in this manner, OIG can monitor the time required at each step of case review. OIG can ensure that timely case review is taking place and identify any problems that the data reveal.


II.D.7

Benchmark II.D.7 - Assign OIG staff to monitor agency-conducted investigations.

FY 2007 Result - OIG assigns a "buddy" investigator on agency investigations.


When a bureau assigns an investigation to an OIG-authorized agency, the bureau continues to monitor the investigation to ensure its timely and effective completion. Each bureau assigns a member of its investigative team to act as a "buddy" to the agency investigator. The "buddy" investigator reviews the investigative plan, monitors the investigation, contacts the agency investigator to ascertain progress, serves as a resource for any questions and reviews the final case report. The buddy may also directly assist and participate in the investigation if necessary. The agency investigator must adhere to requirements and due dates set by the bureau. The bureau chiefs also review the cases to make sure that the agency investigator has conducted a complete and comprehensive investigation. As with OIG-conducted investigations, OIG's Deputy Inspector General reviews all substantiated cases investigated by agency staff.


Initiative E: Streamline Registry appeals hearing process.


II.E.1

Benchmark II.E.1 - By December 31, 2006, find process to stipulate non-referral.

FY 2007 Result - A stipulation process was formalized September 11, 2006.


In FY 2005, OIG began reviewing every decision by an administrative law judge (ALJ) in Health Care Worker Registry referral appeals. In FY 2006, the Inspector General designated an OIG Legal Liaison, to improve preparation of Registry cases with the DHS Office of General Counsel - the attorneys who represent OIG at Registry hearings - and to review all Registry decisions.

Over time, OIG and the DHS Office of General Counsel realized that not all substantiated physical abuse findings warrant placement on the Registry. So, together, they developed a process that is authorized by the regulations governing such hearings. This process involves "stipulating" that certain physical abuse cases, while meeting the broad definition of physical abuse, do not deserve placement on the Registry. This new process was approved by DHS Secretary Adams on September 11, 2006.

The process applies where a person's identity is to be placed on the Registry for a substantiated physical abuse finding and the person petitions for a hearing (50.90 appeal) on the basis that the act was not serious enough to deserve placement. The process then includes input from OIG and the Office of General Counsel. However, the final decision about placement on the Registry remains with the ALJ and the Secretary of DHS. If they agree, the matter is resolved without a formal hearing and the person's name is not reported to the Registry. However, the finding remains substantiated physical abuse.

During FY 2007, four petitioners' hearings were resolved using this stipulation process.


II.E.2

Benchmark II.E.2 - Train OIG staff on testifying by June 30, 2007.

FY 2007 Result - OIG testifying training held March 30, 2007 and April 4, 2007.


After reviewing decisions by the administrative law judge in Registry appeals, OIG decided to provide additional training for its investigators in how to prepare for and provide testimony in court proceedings and administrative hearings. This training was finalized on December 4, 2006. The training covered the following topics: types of hearings; definitions; case coordination; investigator preparation and professionalism; providing testimony; and testimonial demeanor.

To provide this training in person, OIG held two training sessions. The first was held on Friday, March 30, 2007, at the OIG office location in the Chicago suburb of Hines. The second was held on Thursday, April 5, 2007, at the Lebanon Chamber of Commerce. OIG has also incorporated information from this training into the curriculum for its new employee orientation training.


Initiative F: Draft legislative revisions to update statute.


II.F.1

Benchmark II.F.1 - By March 31, 2007, draft bill to move OIG to DHS statute.

FY 2007 Result - This bill (Senate Bill 1368) was filed on February 9, 2007.


OIG is part of the Department of Human Services (DHS), but OIG's enabling statute has been part of a Department of Public Health (IDPH) law: the "Abused and Neglected Long Term Care Facility Residents Reporting Act" (210 ILCS 30/6).

Therefore, OIG drafted a bill to move all of the sections governing OIG to become a new section in the DHS Act (20 ILCS 1305/1-17). The bill was introduced in the Senate on February 9, 2007. The only substantive change was to reflect IDPH changing the name of the Nurse Aide Registry to the Health Care Worker Registry. Corresponding changes to three other laws: DHS's Mental Health and Developmental Disabilities Administrative Act (20 ILCS 1705), and IDPH's Nursing Home Care Act (210 ILCS 45) and Health Care Worker Background Check Act (225 ILCS 46).

This bill passed the legislature on May 31, 2007, and was sent to the governor on June 29, 2007. Governor Blagojevich signed it August 28, 2007 (Public Act 95-545), after the end of FY 2007.


II.F.2

Benchmark II.F.2 - By March 31, 2007, draft bill to deter false allegations.

FY 2007 Result - This bill (Senate Bill 1364) was filed on February 9, 2007.


Current or former employees sometimes report allegations against a community agency or facility in an apparent effort to harass or retaliate against another employee, cause embarrassment, or disrupt program operations. These allegations also tie up valuable resources of OIG in investigating these allegations, which the employee knows to be false.

To address this issue, OIG drafted a bill to directly confront such false reporting. The bill proposed to make such false reporting a crime. Specifically, Senate Bill 1364 proposed that anyone who knowingly makes a false allegation to OIG is committing a disorderly conduct offense and is guilty of a Class B misdemeanor. Any repeated conviction would be a Class 4 felony.

However, OIG's entire statute was already in revision (see Benchmark II.F.1 above) and the legislature was reviewing the Criminal Code. Thus, after the bill passed committee and made it to the full Senate, a decision was made to hold off on the proposal and address it during the Spring Session 2008, by which time OIG's enabling statute will have been moved to the DHS Act.


II.F.3

Benchmark II.F.3 - By March 31, 2007, draft bill to avoid guardian ad litem fees.

FY 2007 Result - This bill (Senate Bill 452) was filed on February 8, 2007.


The law creating the OIG's Domestic Abuse Program mandates that OIG seek temporary guardianship whenever the current guardian is alleged to be the perpetrator of abuse, neglect, or exploitation and there is an urgent and immediate necessity to protect the alleged victim.

Temporary guardianship involves legal work and the appointment of a guardian ad litem, which also involves expenses. Unlike other similar State entities, OIG did not have a specific exemption from having to pay these fees.

In the fall of 2006, OIG drafted a bill to add to the Probate Act of 1975 a specific exemption from legal fees for OIG. Senate Bill 452, which was introduced on February 8, 2007, proposed that no guardian ad litem or legal fees shall be assessed against OIG when petitioning for guardianship under the Abuse of Adults with Disabilities Intervention Act (20 ILCS 2435). This bill passed the legislature and, on June 27, 2007, was sent to the governor for signature. Governor Blagojevich signed it August 23, 2007 (Public Act 95-373), after the end of FY 2007.


II.F.4

Benchmark II.F.4 - By June 30, 2007, draft revisions to Rule 50, as needed.

FY 2007 Result - No statutory changes requiring Rule 50 revisions were passed.


An administrative regulation spells out in more detail how a law will be implemented. Since it goes before a committee of the General Assembly - the Joint Committee on Administrative Rules - for review, if the committee does not object, a regulation carries the force of law. The administrative regulation governing abuse/neglect allegations of individuals receiving developmental disability or mental health services in a DHS facility or a local community agency is Illinois Administrative Code, Title 59, Chapter I, Part 50, commonly known as Rule 50.

Since the statutory changes made in FY 2007 did not substantially affect existing procedures or requirements in the rule, OIG needed to make no revisions to Rule 50. 


Priority III - Supporting quality programs

Table 15 - Detailed Performance Scorecard for Priority III Strategic Objective: Supporting quality programs
Initiative Benchmark Measure Performance Measurement Performance Result Performance Trend (and 3-year trend*)
A. Ensure timely initial reporting by community agencies and facilities.

1) By 7/31/06, require at least biennial training in Rule 50.

2) By 6/30/07, make sure 90% agencies' reporting policy have all needed elements.

3) By 6/30/07, revise DHS directive on reporting.

4) Update Rule 50 training by 2/28/07.

5) Update Handbook on Reporting, by 12/31/06.

6) Continue to cite late reporting.

1) Required of DD agencies 7/1/06, MH agencies 9/15/06, facilities during FY 2007 site visits.

2) By 6/30/07, 363 of 372 agency policies had all elements.

3) Draft submitted 11/17/06. Pending.

4) Rule 50 training completed, but not approved.

5) Handbook revised 9/25/06 and on 2/2/07; printed 3/21/07.

6) Failure to report or late reporting were cited in 217 cases.

1) 100%


2) 108%


3) 100%


4) 90%


5) 100%


6) 100%

1) N/A


2) N/A


3) N/A


4) N/A


5) N/A


6) Improvement

B. Authorize com-munity agencies to investigate, when appropriate. 1) Authorize 190 community agencies for FY 2007. 1) Authorized 162 agencies for FY 2007. 1) 85% 1) Improvement

* Three-year trend, where applicable, covers FY 2005 through FY 2007.


Summary for Priority III: Supporting quality programs

This section displays results for this FY 2007 strategic objective and related initiatives by specific benchmark measure. It summarizes OIG performance during the fiscal year, and the narrative that follows provides relevant detail about each benchmark.

FY 2007 Summary for Priority III Strategic Objectives
Related Initiatives Total Benchmarks Average Results Targets Met
2 7 97.6% 71.4%

Related initiatives for this strategic objective: 

  1. Ensure timely initial reporting by community agencies and facilities 
  2. Authorize community agencies to investigate, when appropriate

Initiative A: Ensure timely initial reporting by community agencies and facilities.


III.A.1

Benchmark III.A.1 - By July 31, 2006, ensure at least biennial training in Rule 50.

FY 2007 Result - OIG and DHS set training requirement by September 15, 2006.


OIG recognizes that regular training in reporting abuse and neglect of individuals receiving mental health or developmental disability services is an important step in raising awareness and both preventing it and reporting it when it allegedly happens. The timeliness of reporting would thus be improved by regular training in OIG Rule 50, and so OIG set a strategic benchmark to work toward ensuring at least biennial training of all agency and facility staff in Rule 50.

Following discussions at the OIG Program Coordination workgroup, beginning July 1, 2006, the Division of Developmental Disabilities included a requirement for biennial training in the FY 2007 Community Agency Service Agreement. Then, on September 15, 2006, the Inspector General and the Director of the Division of Mental Health sent a letter to all mental health community agencies licensed, funded, or certified by DHS, informing them of the new training requirement. This letter stipulated that this biennial training requirement applies to all existing employees, new hires, contractors and volunteers.

OIG also made recommendations during the FY 2007 facility unannounced site visits - which began July 27, 2006 - to revise their internal training policy to specifically require OIG Rule 50 training at least biennially. Most facilities, as well as many community agencies, use a computer-based learning module that OIG developed during FY 2006.


III.A.2

Benchmark III.A.2 - By June 30, 2007, ensure agency reporting policies have all elements.

FY 2007 Result - OIG approved 331 of 373 agencies' policies by June 30, 2007.


In FY 2006, OIG did a review of 96 community agencies that had not reported any allegations since at least January 2002. OIG found that several had closed, merged, or did not provide direct services. Of the rest, only six had reporting policies that addressed the four key elements of OIG Rule 50:

  • Definitions of abuse, neglect, and eight other important terms;
  • Prohibition of screening (withholding) of allegations by agency administrators;
  • Time frames for reporting to OIG; and
  • Requirements for preserving evidence and securing the scene.


As a result, OIG decided to review the abuse/neglect reporting policies of all 386 community agencies; thirteen of those have since indicated they no longer serve individuals who are under OIG's investigative jurisdiction. By June 30, 2007, 363 of those 373 (97%) had responded by submitting their reporting policies. OIG is working with the DHS Division of Mental Health and the DHS Division of Developmental Disabilities to obtain policies from the remaining ten.

Again, few agencies submitted policies that covered all four key elements. OIG worked with the agencies to improve their reporting policies, and, as of June 30, OIG had approved 331 (91%) of the 363 agencies' policies and was working with the other 32 (9%) to correct deficiencies.


III.A.3

Benchmark III.A.3 - By June 30, 2007 revise DHS directive on reporting.

FY 2007 Result - OIG submitted a revision to the directive on November 17, 2006.


A single DHS policy governs reporting of abuse/neglect allegations and deaths at all DHS mental health or developmental centers. This directive, "Reporting and Investigating Incidents and Allegations of Abuse and Neglect" (DHS Program Directive 02.01.06.020), was last revised in 2002. During the initial phase of reviewing the community agencies' reporting policies (see Benchmark III.A.1), it became apparent that this program directive needed to be updated. Thus, OIG set a goal of revising the DHS directive by June 30, 2007.

OIG's submitted a proposed revision on November 17, 2006. The proposed directive has been under review by all DHS stakeholders and is expected to be promulgated in late 2007.


III.A.4

Benchmark III.A.4 - Update Rule 50 training by February 28, 2007.

FY 2007 Result - The Rule 50 training module was in draft as of June 30, 2007.


In FY 2006, OIG had sent all community agencies and DHS facilities a self-running training module on Rule 50, the administrative regulation that governs the reporting of abuse and neglect. This training module, capable of running on any Windows-based computer without additional software, ensured that all direct care staff received a clear and consistent presentation of Rule 50's requirements.

For FY 2007, OIG set a goal to update this training module to include five new laws that had been signed in 2006. After several attempts at simply inserting the laws, however, OIG decided to revise the training to use a scenario approach. That is, five scenarios would illustrate the relevant topics in real-life situations, thereby improving comprehension and encouraging discussion.

By the end of FY2007, the scenarios were drafted, but the training module was not yet completed. OIG plans to complete it in early FY 2008.


III.A.5

Benchmark III.A.5 - Update Handbook on reporting by December 31, 2006.

FY 2007 Result - OIG submitted revised Handbook on September 25, 2006.


OIG developed its Handbook for Reporting Abuse and Neglect of Adults with Disabilities in late FY 2005, for distribution to all community agencies and at all OIG-conducted trainings. The Handbook uses a question-and-answer format to address important issues in the reporting and investigating of allegations.

In FY 2006, some important changes occurred that necessitated an update. First, Illinois enacted four new laws that provide more protection to adults with mental and developmental disabilities.

  • Any sexual conduct between an employee and an individual receiving services was made a Class 3 felony, unless the personal relationship pre-dated the service relationship, regardless of any claim of consent. An employee found guilty is required to register as a sex offender and is prohibited from working in any health care setting in Illinois. This was added to the "Reportable to OIG" section of the Handbook. [Public Act 94-1053]
  • Intentionally failing to report an abuse/neglect allegation to OIG - or reporting it late - was made a Class A misdemeanor for a facility or agency employee (including volunteers and contractual staff). The offense is punishable by up to one year in jail and/or up to a $2,500.00 fine. This was added to the "Abuse/Neglect Reporting" section. [Public Act 94-853]
  • OIG was specifically allowed to report possible criminal activity at facilities or agencies to the most appropriate law enforcement entity, whether the Illinois State Police or local law enforcement. The Handbook's question about reporting criminal activity now includes this. [Public Act 94-428]
  • OIG was authorized to disclose findings of Rule 50 investigations to the Illinois Department of Financial and Professional Regulation (DFPR), which investigates allegations made against licensed professionals, such as doctors and nurses. OIG was also authorized to give that department verbal disclosure of OIG's domestic abuse investigative findings, as well as any subsequent referrals. These were placed in a new subsection in the Handbook. [Public Act 94-852]

Further, training requirements were changed. First, DHS instituted a new biennial Rule 50 training requirement for all agency and facility employees. In addition, agency or facility investigative staff will now be required to receive investigative skills training from OIG at least every two years, instead of every three years. Agency-designated staff who function as OIG liaisons must receive Rule 50 training from OIG every two years as well. These requirements were included in the Handbook under "Duties After Reporting."

OIG initially revised its Handbook on Reporting Abuse and Neglect of Adults with Disabilities on September 25, 2006, and sent it for printing.

However, the Illinois Department of Public Health (IDPH) renamed its Nurse Aide Registry to the Health Care Worker Registry. This change was in name only; OIG still reports to the Registry the names of facility or agency employees who have substantiated findings of physical abuse, sexual abuse, or egregious neglect (see Strategic Objective I.F.1). Thus, the Handbook was revised again on February 2, 2007, and printing was done on March 21, 2007. The Handbook is distributed at all OIG-conducted trainings and is also available on the OIG website.


III.A.6

Benchmark III.A.6 - Continue to cite late reporting or failure to report in cases.

FY 2007 Result - OIG cited reporting issues in 217 cases during FY 2007.


When OIG conducts an investigation, one issue that the investigator considers is whether the allegation or death was reported to the OIG Hotline within the required time frame: four hours for any allegation of abuse or neglect, and 24 hours for deaths without any allegation. OIG also looks to see if any agency or facility staff member knew about the allegation earlier and failed to report it at all. OIG has redoubled its efforts at finding and citing reporting issues.

OIG may cite multiple issues on a single Written Response. So, in the 471 approved Written Responses received during FY 2007, OIG had cited a total of 671 issues. The top two issues cited were failure to report (160 cases) and late reporting (57 cases). Together, these two reporting issues were cited on Written Responses for 217 cases and accounted for nearly one-third (32%) of all 671 cited issues. Staff interaction with an individual that is inappropriate but does not meet the definitions of abuse or neglect was the third most common issue (46 cases).

OIG cited these two reporting issues more frequently in FY 2007 than in the two prior years. During FY 2005, the two issues accounted for 145 (28%) of 526 total issues cited; during FY 2006, this dipped to 139 (24%) of 577, and then it rose to 217 (32%) of 671 total issues. OIG will continue to work with the DHS divisions to ensure the timely and complete reporting of allegations to the OIG Hotline.


Initiative B: Authorize community agencies to investigate, when appropriate.


III.B.1

Benchmark III.B.1 - Authorize 190 community agencies for FY 2007.

FY 2007 Result - OIG received requests and authorized 162 agencies in FY 2007.


Rule 50 allows OIG to accept an investigation by a community agency, but only if that agency has already been authorized to investigate and OIG assigns the particular investigation to the agency. Authorization is an annual process and involves the following two aspects.

First, the agency must adopt OIG's Investigative Protocol for Community Agencies, which sets forth specific requirements for all investigations the agency conducts under Rule 50. The agency must formally request authorization from OIG, agreeing to adhere to the standards in the Protocol. Authorization is good for one fiscal year, which ensures a regular review of each agency.

Second, the agency must have at least one employee whom OIG has formally approved as an investigator after reviewing the documentation and confirming that all of the following requirements have been met.

  • The employee must have successfully completed OIG-conducted Rule 50 training since January 1, 2002 and OIG-conducted investigative skills training within the past three years;
  • The employee must not be in any role having an appearance of a conflict of interest - such as being the agency's executive director, assistant executive director, human resource director, member of a collective bargaining unit, or a family member of any of those;
  • The employee must have been identified as an agency investigator either in the agency's current fiscal year authorization request or in a later request from the agency; and
  • The employee must not have any substantiated finding of abuse or neglect.


Although OIG may ask agency staff to take initial steps, such as getting medical exams, preserving evidence, and collecting written statements, an agency may conduct the full investigation only if it has been authorized and only when OIG assigns the particular investigation to it. OIG has been allowing agencies to investigate only allegations of mental injury or neglect without serious injury.

FY 2007 Authorizations

During FY 2007, a total of 372 community agencies were under OIG's investigative jurisdiction, but 24 of them do not provide direct care to individuals. Thus, only 348 agencies would be eligible for investigative authorization. Of these 348 agencies, 162 agencies submitted requests and were authorized by OIG to investigate on a case-by-case basis. The remaining 186 agencies opted for OIG to conduct investigations. All agencies are still required to comply with statutory and Rule 50 requirements regarding reporting and investigating.

Trend over four fiscal years

The number of community agencies authorized to investigate has fluctuated over the last four years. The table below shows the number of agencies authorized by OIG in each fiscal year and, just for comparison purposes, the total number of agencies within OIG investigative jurisdiction and the percentage of those that were authorized.

Table 16 - Community Agencies Authorized to Investigate, FY 2004 through FY 2007
Fiscal Year Authorized agencies Total agencies Overall percentage
FY 2004 191 399 47.9%
FY 2005 184 394 46.7%
FY 2006 129 386 33.4%
FY 2007 162 372 43.5%

The drop in agencies approved to investigate during FY 2006 was due to several factors, including an increase in training required and the limitation in the types of investigations that OIG permits agencies to investigate.

For FY 2007, OIG set a strategic benchmark to increase the number of authorized agencies to 190, back to the higher level of prior years. Through additional initial information and follow-up contacts, OIG encouraged more agencies to apply. OIG also sought to address concerns of some agencies by structuring ongoing direct support from an OIG investigator (see Strategic Objective II.D.7). The 162 authorized agencies fell short of the goal but was substantially higher than in FY 2006.


Priority IV - Partnering with others

Table 17 - Detailed Performance Scorecard for Priority IV Strategic Objective
Initiative Benchmark Measure Performance Measurement Performance Result Performance Trend (and 3-year trend*)
A. Collaborate with stakeholders to reduce occurrence of abuse/neglect.

1) Ensure Quality Care Board meets quarterly in FY 2007.

2) Act as liaison with the Office of Executive Inspector General.

3) Conduct quarterly OIG Coordination meetings.

4) Conduct customer satisfaction survey by 4/30/07.

1) Board met once in each quarter in FY 2007.


2) Continued its liaison role.


3) Committee met four times, once per quarter.


4) Survey done 2/2/07-4/2/07; report on 4/4/07.

1) 100%


2) 100%


3) 100%


4) 100%

1)Improvement


2) N/A 


3) No change


4) N/A 

B. Utilize external resources for improved training. 1) Arrange five outside trainings of OIG staff by 6/30/07. 1) OIG staff went to eight trainings by 6/30/07. 1) 160% 1) Improvement
C. Ensure first response training of selected staff. 1) Conduct 12 First Responder trainings in FY 2007. 1) 13 conducted in FY 2007. 1) 108% 1) Improvement
D. Expand partnerships with law enforcement regarding OIG's mission.

1) By 12/31/06, include date/time of credible evidence on DII/LLE report form.

2) By 6/30/07, revise Directive to specify responsibility.

3) By 6/30/07, begin monitoring referrals.

4) Present to three law enforcement entities.

1) Form revised 12/6/06.

2) Directive revised 2/23/07.

3) Case reviews entered and monitored.

4) Presented to three law enforcement entities in FY 2007.

1) 100%


2) 100%


3) 100%


4) 100%

1) N/A


2) N/A


3) N/A


4) Improvement

*Three-year trend, where applicable, covers FY 2005 through FY 2007.


Summary for Priority IV: Partnering with others

This section displays results for this FY 2007 strategic objective and related initiatives by specific benchmark measure. It summarizes OIG performance during the fiscal year, and the narrative that follows provides relevant detail about each benchmark.

FY 2007 Summary for Priority IV Strategic Objectives
Related Initiatives Total Benchmarks Average Results Targets Met
4 10 106.8% 100.0%

Related initiatives for this strategic objective:

  1. Collaborate with stakeholders to reduce occurrence of abuse/neglect
  2. Utilize external resources for improved training
  3. Ensure first response training of selected staff
  4. Expand partnerships with law enforcement regarding OIG's mission

Initiative A: Collaborate with stakeholders to reduce occurrence of abuse/neglect.


IV.A.1

Benchmark IV.A.1 - Ensure Quality Care Board meets quarterly in FY 2007.

FY 2007 Result - The Quality Care Board met in each quarter during FY 2007.


The Quality Care Board was initially authorized in 1992 (P.A. 87-1158) to "monitor and oversee the operations, policies, and procedures" of OIG and to provide consultation on OIG policies, protocols, review regulations, advise on training, and recommend ways to improve OIG's intergovernmental relationships. As specified in the law, the Board is to meet at least quarterly: during FY 2007, it met on August 30, 2006, October 31, 2006, January 24, 2007, and April 24, 2007.

The Board has seven members, who are appointed by the Governor with advice and consent of the State Senate and must be qualified by professional knowledge or experience in the areas of law, investigatory techniques, or the care of those with mental illness or developmental disabilities. At least two must either have a disability or have a child with a disability. The members are not paid but may be reimbursed for travel and other relevant expenses. The OIG Quality Care Board members serving during FY 2007 were the following:

  • Rita Ann Burke (Makanda), appointed July 8, 2005;
  • Thane A. Dykstra (Joliet), appointed July 8, 2005;
  • Nathaniel Gibson (Springfield), appointed June 29, 2005;
  • Keith W. Kemp (Chicago Heights), appointed June 24, 2005;
  • Brian Neal Rubin (Buffalo Grove), appointed June 24, 2005;
  • Rick Karpawicz (Morton), appointed September 1, 2006; and
  • Maria Ester Lopez (Chicago), appointed September 1, 2006.


During FY 2007, the Board members discussed issues such as the DHS Division of Mental Health and OIG's involvement in the law enforcement training of new recruits of the Chicago Police Department regarding consumers, focusing on how to manage situations with mental health concerns.

The Board members also reviewed OIG's quarterly reports on the status of cases, including the number opened and closed, the timeliness of investigations, and the findings, as well as OIG's progress on its strategic objectives and related benchmarks. The Board members discussed the report of the Auditor General's FY 2005-2006 program audit of OIG and the corrective actions that OIG planned and had implemented.

Finally, various OIG staff gave presentations on the functions of the office. The presentations allowed the Board members to get a better idea of how OIG works and to ask questions of the staff. At the quarterly meetings in FY 2007, the following presentations were provided: Bureau of Hotline and Intake; death investigations by OIG's Clinical Coordinators; Written Response Compliance Reviews; and the Adults with Disabilities Domestic Abuse Intervention Program (Rule 51).

OIG greatly appreciates the time and efforts of the Quality Care Board members.


IV.A.2

Benchmark IV.A.2 - Act as DHS liaison with the Office of Executive Inspector General.

FY 2007 Result - OIG continued its liaison role in FY 2007.


OIG serves as DHS's liaison with the Office of Executive Inspector General under the Governor, pursuant to the Governor's Executive Order 3 and Administrative Order 6. The Office of Executive Inspector General routinely requests OIG to gather information from DHS as part of investigations or inquiries that office may be conducting. As liaison, OIG also forwards to the Office of Executive Inspector General any reports of alleged employee misconduct received from DHS management or through OIG's Hotline.


IV.A.3

Benchmark IV.A.3 - Conduct quarterly OIG Coordination meetings.

FY 2007 Result - OIG Coordination meetings were held quarterly in FY 2007.


OIG actively works with the DHS divisions and other state agencies to discuss information and plan joint activities. This collaboration enables the efforts of each to accomplish more, to expand the effectiveness of individual efforts. OIG's collaboration is with entities sharing a common goal: to increase successful outcomes in activities aimed at preventing abuse and neglect of individuals with disabilities and to maintain the confidence of their families and the public.

The OIG Program Coordination workgroup discusses high risk incidents, shared issues, and trends/patterns in abuse and neglect allegations and findings, identifying solutions aimed at preventing abuse and neglect within community agencies and DHS facilities. Standing members of the workgroup include the following:

  • Division of Developmental Disabilities;
  • Division of Mental Health;
  • Division of Rehabilitation Services;
  • Bureau of Accreditation, Licensure and Certification;
  • Illinois Department of Public Health; and
  • Illinois Department of Healthcare and Family Services.


Other stakeholders, such as advocacy groups and associations, may be invited when appropriate. During FY 2007, the workgroup met on: July 20, 2006; October 19, 2006; January 11, 2007; and April 19, 2007.

Initiatives

The OIG Program Coordination workgroup successfully collaborated and implemented many initiatives during FY 2007. The workgroup members discussed issues from the perspective of their division or department, seeking an integrated approach for solutions or further monitoring, such as holding a meeting or sending a letter to an agency or facility with recommendations. Where initiatives had begun in FY 2006, the workgroup members discussed progress and possible improvements to the initiatives.

All of these initiatives facilitated prevention efforts, improved cost-effectiveness, or made them easier to monitor, and thus easier to maintain. Some examples of these issues and the workgroup's solutions follow.

Issue: Infrequent Training

Since Rule 50 has specific mandates for employees of community agencies and DHS facilities, OIG has expected that all of those employees receive and follow training in Rule 50. However, investigative findings have shown that some of these employees claimed to either not remember or not know the reporting requirements (i.e., definitions, time frames, responsibility for reporting allegations, etc.), and OIG has recommended re-training of staff. 

Solution: Biennial Refresher

The workgroup agreed to require all community agencies and facilities to require refresher training for employees, including contractual employee and volunteers, every two years (see Strategic Objective II.A.1). The Division of Mental Health and OIG jointly issued a letter to MH community agencies informing them of the training requirement, and the Division of Developmental Disabilities included the requirement in the FY 2007 Community Agency Service Agreement. In addition, the training requirement is one of the monitoring indicators of the regional offices and is being reviewed regularly for compliance.


Issue: Insufficient Training Materials

Facilities and community agencies needed updated materials to use for training of their employees on Rule 50. New laws had been passed in FY 2006 that needed to be incorporated into OIG's "Handbook for Reporting Abuse and Neglect of Adults with Disabilities" and into the OIG-created Rule 50 training module, which is used by facilities and agencies for internal training.

Solution: Updated Materials

With the assistance of its DHS partners, OIG updated its handbook on reporting, expanded its training on Rule 50, revised the community agency investigative protocol, and, as noted below, created a sample policy on reporting abuse and neglect. This policy and the updated handbook were placed on the OIG website in a printable format. OIG further committed to updating the Rule 50 training module, which is in electronic format on the OIG website (see Strategic Objectives III.A.3 and III.A.4).


Issue: Inadequate Policies

A review of the investigative case finding revealed that over half of the required Written Responses included a recommendation that the agency develop a policy or train/re-train staff on Rule 50 and, in particular, the responsibility for reporting alleged abuse and neglect. The underlying problem was that the agency's policy on reporting was inadequate.

Solution: Thorough Review

In October 2006, OIG sent a letter to each community agency requesting a copy of its abuse and neglect reporting policy, to ensure that each policy has the key elements of Rule 50: defined abuse and neglect; included the time frames for reporting; prohibited screening by administration; described a process for preserving evidence. In the letter, OIG included a copy of a sample abuse and neglect policy that the community agency could customize. By the end of the fiscal year, well over ninety percent of the agency policies were in compliance (see Strategic Objective III.A.2).


Issue: NonReportables Minimized

Complaints received by the OIG Hotline which do not meet the Rule 50 definitions of allegations are called "NonReportables," and OIG had not been saving these in its database. OIG had been referring these NonReportables to the appropriate division or agency for follow-up but had not been tracking them in the database, leaving it to the divisions to document the kinds complaints, types of referrals made, or reasons for a disposition. OIG Program Coordination workgroup members had frequently asked questions about a formal process for referring non-reportable allegations and any trends and patterns observed. 

Solution: NonReportables Examined

With the expansion of the database to save NonReportables, OIG now produces a NonReportable intake that has a unique number and a "code" for complaint type, referral or reason code (see Strategic Objective II.A.1). These intakes can be immediately emailed to the appropriate division or state agency similar to the reportable intake reports. OIG will also now be able to track and analyze these NonReportables, allowing OIG Program Coordination workgroup members to discuss situations and statistics about these complaints. This process is similar to the existing process for allegations of abuse or neglect, in which those that are high risk and/or occur frequently within an agency/facility or group of agencies/facilities may form a pattern, which flags consideration.


Issue: Registry Checks

Employees whose names are indicated in the IDPH Health Care Worker Registry (formerly, Nurse Aide Registry) are barred from employment in direct care positions in any facility or agency that DHS operates, funds, certifies, or licenses. Each facility administrator has been required to ensure that checks of all facility employees are made at least monthly, since names are added monthly. Yet, in most cases, the facility administrator would already know about substantiated findings that would require a report to the Registry involving any facility employee. For new DHS employees, the DHS Bureau of Recruitment and Selection checks for each potential employee's name on the Registry. In cases where a current facility employee has a substantiated Registry-reportable finding at an agency, the facility would not know until it was posted by IDPH and then checked by the facility.

Solution: Single Checker

After discussion, OIG worked with DHS Bureau of Employee Services to develop a system to complete an electronic check of all current DHS employees each time OIG submits a referral to the IDPH Health Care Worker Registry. Checks are no longer required by the facility/hospital administrator. This is an improvement in the timely, efficient and effective handling of this important task.

Other Collaboration

OIG also participates on the DHS Proactive State-Operated Facilities Committee, which focuses on improving services and resources with DHS's nine mental health centers and nine developmental centers. By participating, OIG is able to promptly collaborate with DHS operations administrators and facility administrative staff to address issues of patient safety within the facilities.

In addition, OIG serves as a member of the Advisory Board for Equip for Equality, which is the federally appointed protection and advocacy agent for the state of Illinois.


IV.A.4

Benchmark IV.A.4 - Conduct customer satisfaction survey by April 30, 2007.

FY 2007 Result - OIG conducted a survey and an internal report by April 4, 2007.


To obtain and examine external stakeholder feedback to help improve its services, OIG developed a survey of the directors of the DHS facilities and agencies that provide mental health and developmental disability services. The five areas of OIG's statutory authority addressed in the survey were: unannounced site visits (DHS facilities only); OIG-conducted training; Hotline/Intake; Investigations; and Written Response Compliance Reviews. For each area, between five and nine statements were listed. The respondents were asked to rate their reactions to each statement from 1 (Strongly Disagree) to 5 (Strongly Agree). Written comments and examples were encouraged.

On February 2, 2007, OIG e-mailed or mailed surveys to all these directors, as well as to relevant program administrators in DHS. Responses were completed by March 30, 2007. Responses were received from thirteen of the eighteen facilities (72%), and 200 of the 377 agencies (53%).

The survey found that the majority of facilities and agencies are satisfied with OIG's performance. For half of the statements - 17 of 35 - over 90% of the respondents gave OIG high ratings and comments were uniformly positive. Few differences in ratings or comments were evident between facility and agency responses, indicating that OIG is seen as even-handed in its dealings.

Particularly high marks were given to the professionalism of OIG staff in all areas. Materials used for OIG training were clear and updated and respondents were satisfied with the types of trainings that OIG provides. Intake investigators adequately explain why a call is not reportable and, if unsure, get back quickly with a decision, although agencies seemed to be less familiar with the intake process than did the facilities.

Respondents encouraged OIG to continue efforts to improve the timeliness of the written reports of unannounced facility site visits. Timeliness of OIG investigations was a primary concern for both agencies and facilities, and OIG's efforts in this area were appreciated. OIG continues to take steps to improve timeliness without reducing the quality of its statutory responsibilities.


Initiative B: Utilize external resources for improved training.


IV.B.1

Benchmark IV.B.1 - Arrange five outside trainings of OIG staff by June 30, 2007.

FY 2007 Result - OIG staff received eight outside trainings in FY 2007.


In an effort to get additional expert training for its employees, OIG set a strategic benchmark to arrange five outside trainings during FY 2007. OIG appreciates the assistance of other State agencies in allowing OIG staff to attend existing trainings, especially the Illinois State Police and the Illinois Department of Healthcare and Family Services.

During FY 2007, OIG obtained the following eight investigations-related trainings for its staff:

  • On September 19, 2006, four investigators attended a full-day Illinois State Police training on crime scene protection and evidence handling;
  • On October 10, 2006, eight investigators attended a three-day interview and interrogation training at the Illinois State Police Academy in Springfield; * On October 27, 2006, eighteen OIG staff received a two-hour overview training on state regulations affecting community agency program operations (Rule 115, 119, and 132);
  • On January 9 or 10, 2007, ten OIG investigators and supervisors attended a two-hour seminar on treating individuals receiving services with respect;
  • On April 9, 2007, twenty-one OIG investigators and supervisors attended a three-hour review on managing a disaster;
  • On April 10, 2007, ten OIG supervisors participated in a two-hour seminar on managing internal affairs investigations by a Deputy Superintendent of the Chicago Police Department;
  • On April 10, 2007, eleven investigators and supervisors attended a nine-hour review of interview and interrogation training; and
  • On June 7, 2007, the two OIG clinical coordinators and one compliance reviewer attended the Southern Illinois University School of Medicine's Clinical Updates Conference.


In addition, eleven OIG supervisors received a two-day labor relations training by DHS Employee Services on January 23-24, 2007, February 28-March 1, 2007, or March 20-21, 2007.


Initiative C: Ensure first response training of selected staff.


IV.C.1

Benchmark IV.C.1 - Conduct 12 First Responder trainings in FY 2007.

FY 2007 Result - OIG conducted 13 First Responder trainings in FY 2007.


Since OIG investigators cannot always be at every one of the thousands of program locations around the state, OIG must rely on administrative and security staff to take initial actions in response to allegations and incidents. Rule 50 requires the authorized representative or his/her designee to "ensure the immediate health and safety of involved individuals and employees" whenever the allegations may involve abuse or neglect.

OIG-trained investigators may begin interviewing after OIG is notified, but OIG conducts a more limited training aimed at the other immediate actions that Rule 50 specifies. These depend on the allegation but are the following:

  • Identifying and separating potential witnesses;
  • Securing the scene of the alleged incident;
  • Identifying and recording the names of everyone at the scene at the time of the alleged incident and everyone who entered the scene prior to it being secured;
  • Taking photos of the scene and of any injuries; and
  • Securing all relevant documents and physical evidence, such as clothing.

By conducting this "First Responder" training, OIG is increasing the number of agency/facility staff who are competent in taking the immediate actions short of interviewing or investigating.

OIG developed this training shortly before the start of FY 2006 and set a goal to annually conduct twelve of these trainings around the state. During FY 2007, OIG conducted 13 First Responder trainings.

  • Northern Illinois: Rockford, Lake Zurich (Lake County)
  • Cook County: Two in Chicago, two in Tinley Park
  • Central Illinois: Joliet, Rock Island, Bloomington, Springfield
  • Southern Illinois: Alton, Centralia, and Anna (Union County)

Seven of the trainings were conducted at community agency locations, and six were conducted at DHS facilities. However, many agency staff attended the training at most facility locations, and some facility staff attended it at agency locations.

OIG has noticed that interest in this training has been waning as agency/facility staff who would be interested in it have often decided to go to the full Basic Investigative Skills course instead. OIG will re-evaluate the focus and presentation of this training.


Initiative D: Expand partnerships with law enforcement regarding OIG's mission.


IV.D.1

Benchmark IV.D.1 - By December 31, 2006, revise DII/LLE reporting form.

FY 2007 Result - OIG issued a revised reporting form on December 6, 2006.


OIG is required to report allegations of possible criminal acts to the Illinois State Police's Division of Internal Investigation (DII) and to local law enforcement (LLE) entities. To document such reporting, OIG uses a form entitled "Checklist for Notification to ISP / Local Law Enforcement," which is an adaptation of a form that DII uses for documenting receipt of referrals.

Since that form is used for reporting from all sources, it has required the date and time the reporter discovered or became aware of the alleged incident. However, state law mandates that OIG report allegations to the Illinois State Police or appropriate local law enforcement entity "within 24 hours after determining that a reported allegation of suspected abuse or neglect indicates that any possible criminal act has been committed or special expertise is required" (20 ILCS 1705/1-17). That is, OIG must report an allegation within 24 hours of determining that there is credible evidence that the criminal act may have been committed.

OIG had no consistent approach to documenting the date and time that this determination was made. As the Auditor General pointed out, revising the form to include that date and time would facilitate checking for compliance. Thus, on December 6, 2006, OIG issued a revised version of the form that includes the date and time that OIG determined there was credible evidence that the criminal act may have been committed.


IV.D.2

Benchmark IV.D.2 - By June 30, 2007, specify responsibility for reporting to ISP.

FY 2007 Result - OIG revised the relevant directive on February 23, 2007.


In response to two recommendations in the program audit by the Office of the Auditor General, the OIG Directives Review Committee reviewed two directives that dealt with reporting to law enforcement. The committee decided to rescind both of these directives and write one new one: "Law Enforcement Involvement" (INV 07-004). The changes became effective February 23, 2007.

This new directive covers all cases with law enforcement involvement and, since it is more concise, should reduce confusion in this area. The directive retains the statutory requirement for notifying law enforcement within 24 hours of the time that OIG determines there is credible evidence that a criminal act may have occurred. The notification form for law enforcement involvement was also revised to include the time, as well as the date, that OIG makes that credible evidence determination.

In addition, OIG Intake investigators will continue to ensure that any non-reportable calls they receive about possible felonies are still reported to the Illinois State Police or the appropriate local law enforcement agency within the time frame.


IV.D.3

Benchmark IV.D.3 - By June 30, 2007, begin monitoring timeliness of referrals.

FY 2007 Result - OIG revised the relevant directive on February 23, 2007.


By law and interagency agreement, OIG reports all possible criminal acts to the appropriate law enforcement entity, which typically means to the Illinois State Police for those at DHS facilities and to local law enforcement agencies for those at community agency programs. The law requires this report to be made within 24 hours of the time that OIG determines credible evidence of the act, unless a report has already been made to the appropriate law enforcement entity.

Effective February 23, 2007, OIG revised a directive to emphasize the need for reporting within 24 hours of determining credible evidence. Monitoring of timeliness of referrals is the responsibility of the investigative bureau chiefs, who have ultimate responsibility for law enforcement reporting. Also, as noted elsewhere, in December 2006, OIG modified the form for reporting to the Illinois State Police to require the date and time of this determination.

During FY07, OIG reported 53 allegations to the Illinois State Police as possible criminal acts. Of those, nine had already been reported before it was reported to OIG; for example, by the facility, a hospital or the guardian. Of the remaining 44 cases, OIG reported all 44 (100%) within 24 hours of the time credible evidence was determined.


IV.D.4

Benchmark IV.D.4 - Present on OIG to three law enforcement entities.

FY 2007 Result - OIG presented to three law enforcement entities in FY 2007.


Collaboration with law enforcement is a critical part of OIG's role, and OIG has sought to maintain good working relationships with law enforcement entities by giving presentations about OIG's role. For example, the Inspector General presented on OIG to the South Suburban Association of Chiefs of Police in September 2006.

During FY 2007, OIG strengthened an ongoing partnership with the Chicago Police Department (CPD), by seeking to increase officer awareness of OIG and how CPD officers might support OIG investigators needing assistance when responding to complaints of domestic abuse, neglect or exploitation of adults with disabilities. In January 2007, the Inspector General met with the CPD's Chief of Police and Commanding Officer to discuss plans on how to include information about the OIG to detectives working the CPD's Special Victims Unit. In February 2007, the Inspector General made a presentation and provided information about the role of the Illinois Department of Human Services, Office of the Inspector General that would be offered in a on-going training to detectives and new recruits. Then, in April and June 2007, OIG participated in the monthly training program of the CPD's Crisis Intervention Team, providing information on special services for individuals with disabilities. A presentation was given on OIG and how the Crisis Intervention Team can assist OIG in various abuse/neglect situations.

OIG plans to expand on these efforts, providing more information to more law enforcement entities around the state in the coming years. Only through collaborative work can abuse and neglect of individuals with disabilities be prevented.